1447231444 NPI number — NORTHSHORE IMAGING ASSOC LLC

Table of content: (NPI 1447231444)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447231444 NPI number — NORTHSHORE IMAGING ASSOC LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHSHORE IMAGING ASSOC 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:
1447231444
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:
PO BOX 2277
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HAMMOND
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70404-2277
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
985-542-8190
Provider Business Mailing Address Fax Number:
985-543-0031

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15837 PAUL VEGA MD DR
Provider Second Line Business Practice Location Address:
STE 200
Provider Business Practice Location Address City Name:
HAMMOND
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70403-1462
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
985-542-8190
Provider Business Practice Location Address Fax Number:
985-543-0031
Provider Enumeration Date:
11/08/2005

Additional Information

Authorized Official

Authorized Official Last Name:
DONNER
Authorized Official First Name:
E
Authorized Official Middle Name:
MICHAEL
Authorized Official Title or Position:
MANAGING PARTNER
Authorized Official Telephone Number:
985-542-8190

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: 1795372 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9013833 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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