1437328085 NPI number — KENNEWICK RADIOLOGY GROUP PC

Table of content: (NPI 1437328085)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437328085 NPI number — KENNEWICK RADIOLOGY GROUP PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KENNEWICK RADIOLOGY GROUP 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:
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:
1437328085
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/01/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1441
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AMARILLO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79105-1441
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-586-5779
Provider Business Mailing Address Fax Number:
509-586-5178

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
174 FIRST AVENUE NORTH
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ILWACO
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98624
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-642-6304
Provider Business Practice Location Address Fax Number:
360-642-6309
Provider Enumeration Date:
02/28/2008

Additional Information

Authorized Official

Authorized Official Last Name:
RHEE
Authorized Official First Name:
RICHARD
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PROVIDER/OWNER
Authorized Official Telephone Number:
800-941-4365

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 7138209 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 006814 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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