1508533878 NPI number — GREEN RIVER RADIOLOGY, P.C.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508533878 NPI number — GREEN RIVER RADIOLOGY, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GREEN RIVER RADIOLOGY, P.C.
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:
6
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:
1508533878
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/18/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5775 WAYZATA BLVD STE 400
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT LOUIS PARK
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55416-1271
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
866-674-7933
Provider Business Mailing Address Fax Number:
952-513-6880

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1982 W PLEASANT GROVE BLVD STE L
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PLEASANT GROVE
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84062-3268
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-563-0333
Provider Business Practice Location Address Fax Number:
801-563-0335
Provider Enumeration Date:
08/25/2021

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
AHERN
Authorized Official First Name:
RAMONA
Authorized Official Middle Name:
Authorized Official Title or Position:
SPECIAL ASSISTANT SECRETARY
Authorized Official Telephone Number:
952-738-4441

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)