Healthcare Provider Details

I. General information

NPI: 1659580116
Provider Name (Legal Business Name): PACIFIC NORTHWEST RADIOLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1915 E REZANOF DR
KODIAK AK
99615-6602
US

IV. Provider business mailing address

PO BOX 26570
FRESNO CA
93729-6570
US

V. Phone/Fax

Practice location:
  • Phone: 907-486-3281
  • Fax: 907-486-2336
Mailing address:
  • Phone: 541-687-7134
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number314344
License Number StateAK

VIII. Authorized Official

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