1114969532 NPI number — MCKENZIE MEDICAL IMAGING PC

Table of content: (NPI 1114969532)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114969532 NPI number — MCKENZIE MEDICAL IMAGING PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MCKENZIE MEDICAL IMAGING PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
WILLAMETTE VALLEY MAMMOGRAPHY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114969532
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/21/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
960 N 16TH ST
Provider Second Line Business Mailing Address:
SUITE 105
Provider Business Mailing Address City Name:
SPRINGFIELD
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97477-4175
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-726-4699
Provider Business Mailing Address Fax Number:
541-744-6069

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
960 N 16TH ST
Provider Second Line Business Practice Location Address:
SUITE 105
Provider Business Practice Location Address City Name:
SPRINGFIELD
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97477-4175
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-726-4699
Provider Business Practice Location Address Fax Number:
541-744-6069
Provider Enumeration Date:
06/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BRIDGES
Authorized Official First Name:
VICKI
Authorized Official Middle Name:
L
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
541-726-4699

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: C03559 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 018382 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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