Healthcare Provider Details

I. General information

NPI: 1932162906
Provider Name (Legal Business Name): PORTLAND MEDICAL IMAGING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2006
Last Update Date: 10/01/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10538 SE WASHINGTON ST
PORTLAND OR
97216-2809
US

IV. Provider business mailing address

10538 SE WASHINGTON ST
PORTLAND OR
97216-2809
US

V. Phone/Fax

Practice location:
  • Phone: 503-215-8900
  • Fax: 503-215-8920
Mailing address:
  • Phone: 503-215-8900
  • Fax: 503-215-8920

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2085P0229X
TaxonomyPediatric Radiology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2085U0001X
TaxonomyDiagnostic Ultrasound Physician
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License Number
License Number State

VIII. Authorized Official

Name: RONALD KIZZIAR
Title or Position: ADMINISTRATIVE DIRECTOR
Credential:
Phone: 503-215-8900