Healthcare Provider Details

I. General information

NPI: 1164493334
Provider Name (Legal Business Name): PHOENIX RADIOLOGY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/27/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 6TH ST
LEWISTON ID
83501-2431
US

IV. Provider business mailing address

531 4TH AVE
LEWISTON ID
83501-2450
US

V. Phone/Fax

Practice location:
  • Phone: 208-799-5335
  • Fax:
Mailing address:
  • Phone: 208-743-4393
  • Fax: 208-743-4214

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. MARK W PETERSON
Title or Position: OWNER
Credential: M.D.
Phone: 208-743-4393