1679140313 NPI number — PROFESSIONAL PORTABLE RADIOLOGIC SERVICES, INC.

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 1679140313 NPI number — PROFESSIONAL PORTABLE RADIOLOGIC SERVICES, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROFESSIONAL PORTABLE RADIOLOGIC SERVICES, INC.
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:
1679140313
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/08/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
755 CLIFF RD E
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BURNSVILLE
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55337-1545
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
952-915-9779
Provider Business Mailing Address Fax Number:
952-915-9597

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5885 GLENRIDGE DR STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ATLANTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30328-5572
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
866-895-2119
Provider Business Practice Location Address Fax Number:
952-890-9025
Provider Enumeration Date:
06/10/2021

Additional Information

Authorized Official

Authorized Official Last Name:
JOHNSON
Authorized Official First Name:
BRUCE
Authorized Official Middle Name:
ALLEN
Authorized Official Title or Position:
VP-AO
Authorized Official Telephone Number:
303-589-4149

Provider Taxonomy Codes

  • Taxonomy code: 335V00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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