Healthcare Provider Details

I. General information

NPI: 1356390736
Provider Name (Legal Business Name): INTERCITY RADIOLOGY, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2006
Last Update Date: 09/04/2020
Certification Date: 09/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1648 ELLIS ST STE 201
BOZEMAN MT
59715-8811
US

IV. Provider business mailing address

1648 ELLIS ST STE 201
BOZEMAN MT
59715-8811
US

V. Phone/Fax

Practice location:
  • Phone: 406-587-8631
  • Fax: 406-587-1343
Mailing address:
  • Phone: 406-587-8631
  • Fax: 406-587-1343

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: JESSICALEE FANDRICH
Title or Position: CREDENTIALING MANGER
Credential:
Phone: 406-587-8631