1104003482 NPI number — MAUI DIAGNOSTIC IMAGING LLC

Table of content: DR. THU AI PHAN OD (NPI 1679172142)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104003482 NPI number — MAUI DIAGNOSTIC IMAGING LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MAUI DIAGNOSTIC 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:
1104003482
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/29/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1300
Provider Second Line Business Mailing Address:
MAIL CODE 61059
Provider Business Mailing Address City Name:
HONOLULU
Provider Business Mailing Address State Name:
HI
Provider Business Mailing Address Postal Code:
96807-1300
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
425-635-4411
Provider Business Mailing Address Fax Number:
425-637-4646

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
99 S MARKET ST STE 205
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WAILUKU
Provider Business Practice Location Address State Name:
HI
Provider Business Practice Location Address Postal Code:
96793-2259
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
808-242-5832
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/29/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
HALLIDAY
Authorized Official First Name:
SCOTT
Authorized Official Middle Name:
B
Authorized Official Title or Position:
MEMBER OF OWNER
Authorized Official Telephone Number:
425-637-3378

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)