Basic Information
| Provider Information | |||||||||
| NPI: | 1992879746 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DAKOTA PLAINS RADIOLOGY PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 759 | ||||||||
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| City: | WILLISTON | ||||||||
| State: | ND | ||||||||
| PostalCode: | 588020759 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7018391066 | ||||||||
| FaxNumber: | 7018395484 | ||||||||
| Practice Location | |||||||||
| Address1: | 1301 15TH AVE WEST | ||||||||
| Address2: | MERCY MEDICAL CENTER | ||||||||
| City: | WILLISTON | ||||||||
| State: | ND | ||||||||
| PostalCode: | 58801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7017747400 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | MAXWELL | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | KEVIN | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7015702250 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085B0100X | X | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Body Imaging | 2085N0700X | X | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology | 2085N0904X | X | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Nuclear Radiology | 2085P0229X | X | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Pediatric Radiology | 2085R0202X | X | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0204X | X | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2085U0001X | X | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Ultrasound |
ID Information
| ID | Type | State | Issuer | Description | A001 A002 | 01 | ND | TRICARE WPS | OTHER | 12126 | 05 | ND | MEDICAID | 5786 001 | 01 | ND | BLUE SHIELD | OTHER |