1326373713 NPI number — MERCER ISLAND MEDICAL IMAGING, LLC

Table of content: (NPI 1326373713)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326373713 NPI number — MERCER ISLAND MEDICAL IMAGING, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MERCER ISLAND MEDICAL IMAGING, LLC
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:
Provider Other Organization Name Type Code:
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:
1326373713
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/19/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2135
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TACOMA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98401-2135
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
253-761-4200
Provider Business Mailing Address Fax Number:
253-383-3553

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9655 SE 36TH ST
Provider Second Line Business Practice Location Address:
SUITE 107
Provider Business Practice Location Address City Name:
MERCER ISLAND
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98040-3798
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-761-4200
Provider Business Practice Location Address Fax Number:
253-383-3553
Provider Enumeration Date:
10/02/2009

Additional Information

Authorized Official

Authorized Official Last Name:
DWIGHT
Authorized Official First Name:
CHRISTINE
Authorized Official Middle Name:
E.
Authorized Official Title or Position:
CHIEF OPERATIONS OFFICER
Authorized Official Telephone Number:
253-761-4200

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0028ME . This is a "REGENCE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: O255941 . This is a "LABOR & INDUSTRIES, CRIME VICTIMS COMPENSATION" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: G8886633 . This is a "PTAN" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 7148976 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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