1144331141 NPI number — INSTITUTE OF DIAGNOSTIC IMAGING, LLC

Table of content: (NPI 1144331141)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144331141 NPI number — INSTITUTE OF DIAGNOSTIC IMAGING, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INSTITUTE OF 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:
1144331141
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2829 UNIVERSITY DR S
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FARGO
Provider Business Mailing Address State Name:
ND
Provider Business Mailing Address Postal Code:
58103-6050
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
701-297-0305
Provider Business Mailing Address Fax Number:
701-235-4847

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11819 MIRACLE HILLS DR
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
OMAHA
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68154-4428
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
402-898-3630
Provider Business Practice Location Address Fax Number:
402-898-3635
Provider Enumeration Date:
08/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HOFER
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
701-297-0305

Provider Taxonomy Codes

  • Taxonomy code: 261QM1200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 04128 . This is a "BCBS" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".
  • Identifier: 1015837 . This is a "GREAT WEST" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".




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