MEDICARE: DR. GLENN P MORADIAN MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2085R0202X	Diagnostic Radiology Physician	PT11018	ND

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
5	P00203248	OTHER	ID	RR MEDICARE NO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000010149530	OTHER	ID	BS INDIVIDUAL PIN NUMBER
2	74070	OTHER	UT	BC OF IDAHO
3	B4059	OTHER	UT	BC OF IDAHO
4	B5651	OTHER	UT	BC OF IDAHO
6	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
7	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1356349955
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GLENN P MORADIAN MD

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

Provider Business Practice Location Address
First Line	:	1301 15TH AVE W
Second Line	:
City	:	WILLISTON
State	:	ND
Zip	:	58801-3821
Country	:	US
Telephone Number	:	701-774-7401
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/08/2005
Last Update Date	:	10/17/2008

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Directions to “ DR. GLENN P MORADIAN MD” Practice Location

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