Healthcare Provider Details

I. General information

NPI: 1841885357
Provider Name (Legal Business Name): MOUNTAIN RADIOLOGY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/05/2021
Last Update Date: 05/26/2023
Certification Date: 05/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3001 S OCEAN DR APT 929
HOLLYWOOD FL
33019-2870
US

IV. Provider business mailing address

PO BOX 208927
DALLAS TX
75320-2010
US

V. Phone/Fax

Practice location:
  • Phone: 970-945-7564
  • Fax:
Mailing address:
  • Phone: 970-900-6856
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: KEITH M HARRINGTON
Title or Position: VICE PRESIDENT
Credential:
Phone: 424-218-9368