1922006519 NPI number — ADVANCED DIAGNOSTIC RADIOLOGY PC

Table of content: (NPI 1922006519)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922006519 NPI number — ADVANCED DIAGNOSTIC RADIOLOGY PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADVANCED DIAGNOSTIC RADIOLOGY PC
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:
1922006519
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/17/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2537
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WILLISTON
Provider Business Mailing Address State Name:
ND
Provider Business Mailing Address Postal Code:
58802-2537
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
866-338-6472
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1301 15TH AVE W
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WILLISTON
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58801-3821
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-774-7401
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/08/2005

Additional Information

Authorized Official

Authorized Official Last Name:
MORADIAN
Authorized Official First Name:
GLENN
Authorized Official Middle Name:
P
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
208-557-0999

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: IF - 8L493 . This is a "BC NUMBER - IDAHO FALLS" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: POC - 8L501 . This is a "BC NUMBER FOR POCATELLO" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 807083700 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8M916 . This is a "BC OF IDAHO" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 000010149528 . This is a "BLUE SHIELD NUMBER" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 15040 , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".




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