1760636930 NPI number — MEDICAL IMAGING NORTHWEST - GOOD SAMARITAN HOSPITAL IMAGING ALLIANCE

Table of content: (NPI 1760636930)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760636930 NPI number — MEDICAL IMAGING NORTHWEST - GOOD SAMARITAN HOSPITAL IMAGING ALLIANCE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEDICAL IMAGING NORTHWEST - GOOD SAMARITAN HOSPITAL IMAGING ALLIANCE
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:
1760636930
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/14/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1304 FAWCETT AVE STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TACOMA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98402-1900
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
253-761-4200
Provider Business Mailing Address Fax Number:
253-583-8630

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
21110 SR 410 E
Provider Second Line Business Practice Location Address:
#110
Provider Business Practice Location Address City Name:
BONNEY LAKE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98391-8457
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-841-4353
Provider Business Practice Location Address Fax Number:
253-583-8630
Provider Enumeration Date:
11/13/2008

Additional Information

Authorized Official

Authorized Official Last Name:
SEILER
Authorized Official First Name:
DOUGLAS
Authorized Official Middle Name:
P
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
253-761-4200

Provider Taxonomy Codes

  • Taxonomy code: 261QR0200X , with the licence number:  602760002 ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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