Healthcare Provider Details

I. General information

NPI: 1144572173
Provider Name (Legal Business Name): DIRECT RADIOLOGY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/15/2012
Last Update Date: 07/25/2023
Certification Date: 07/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22100 BOTHELL EVERETT HWY
BOTHELL WA
98021-8431
US

IV. Provider business mailing address

22100 BOTHELL EVERETT HWY
BOTHELL WA
98021-8431
US

V. Phone/Fax

Practice location:
  • Phone: 855-687-7237
  • Fax:
Mailing address:
  • Phone: 855-687-7237
  • Fax: 855-673-9190

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. KYLE J HENNEBERRY
Title or Position: CHIEF MEDICAL OFFICER
Credential: MD
Phone: 855-687-7237