Healthcare Provider Details

I. General information

NPI: 1508210287
Provider Name (Legal Business Name): CARL MAYBERRY MBA,CRA,ARRT(R)(CT)
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2016
Last Update Date: 04/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MADIGAN ARMY MEDICAL CTR 9040 JACKSON AVE
TACOMA WA
98431-1100
US

IV. Provider business mailing address

MADIGAN ARMY MEDICAL CTR 9040 JACKSON AVE ATTN:MCHJ-CLQ-C
TACOMA WA
98431-1100
US

V. Phone/Fax

Practice location:
  • Phone: 253-968-2147
  • Fax: 253-968-2024
Mailing address:
  • Phone: 253-968-2147
  • Fax: 253-968-2024

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247100000X
TaxonomyRadiologic Technologist
License Number203671
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: