Healthcare Provider Details

I. General information

NPI: 1144650938
Provider Name (Legal Business Name): DIAGNOSTIC RADIOLOGY PC VEIN CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2013
Last Update Date: 11/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26136 US HIGHWAY 59
FAIRFAX MO
64446-9105
US

IV. Provider business mailing address

PO BOX 3521
OMAHA NE
68103-0521
US

V. Phone/Fax

Practice location:
  • Phone: 308-647-6444
  • Fax: 866-902-2445
Mailing address:
  • Phone: 308-647-6444
  • Fax: 866-902-2445

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: JO A POHL
Title or Position: BILLING MANAGER
Credential: CPC
Phone: 308-647-6444