Healthcare Provider Details

I. General information

NPI: 1861674210
Provider Name (Legal Business Name): MEDICAL IMAGING ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2007
Last Update Date: 10/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1031 7TH ST NE
DEVILS LAKE ND
58301
US

IV. Provider business mailing address

PO BOX 801
DEVILS LAKE ND
58301
US

V. Phone/Fax

Practice location:
  • Phone: 701-662-5247
  • Fax: 701-662-4473
Mailing address:
  • Phone: 701-662-5247
  • Fax: 701-662-4473

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number4523
License Number StateND

VIII. Authorized Official

Name: MRS. DARLA J VETSCH
Title or Position: MGR
Credential:
Phone: 701-662-5247