1629109111 NPI number — RADIOLOGY ASSOCIATES OF DURANGO PC

Table of content: (NPI 1629109111)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629109111 NPI number — RADIOLOGY ASSOCIATES OF DURANGO PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RADIOLOGY ASSOCIATES OF DURANGO 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:
1629109111
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/07/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 394
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRETNA
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68028-0394
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
877-406-2976
Provider Business Mailing Address Fax Number:
719-591-2745

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1010 THREE SPRINGS BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DURANGO
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
81301-8296
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
970-764-2286
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/08/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WALTERS
Authorized Official First Name:
MARK
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
970-259-2525

Provider Taxonomy Codes

  • Taxonomy code: 2085N0904X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0202X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2085R0204X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085U0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: E2677 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: X9X000484 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 209463 . This is a "US DEPARTMENT OF LABOR" identifier . This identifiers is of the category "OTHER".
  • Identifier: 04005427 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 825698 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 10025313600 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: RAB6508 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".




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