Healthcare Provider Details

I. General information

NPI: 1306011473
Provider Name (Legal Business Name): PACIFIC NORTHWEST RADIOLOGY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/29/2008
Last Update Date: 04/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

602 CHASE AVENUE
CORDOVA AK
99574-0160
US

IV. Provider business mailing address

PO BOX 26570
FRESNO CA
93729-6570
US

V. Phone/Fax

Practice location:
  • Phone: 907-424-8000
  • Fax:
Mailing address:
  • Phone: 541-687-7134
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier7140551
Identifier TypeMEDICAID
Identifier StateWA
Identifier Issuer
# 2
IdentifierMDG34OR
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name: BURT LOESSBERG
Title or Position: CEO
Credential:
Phone: 541-687-7134