Healthcare Provider Details

I. General information

NPI: 1003587692
Provider Name (Legal Business Name): ELEVATION MEDICAL IMAGING GILLETTE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/23/2021
Last Update Date: 04/24/2023
Certification Date: 04/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

913 E BOXELDER RD
GILLETTE WY
82718
US

IV. Provider business mailing address

PO BOX 736
WHEAT RIDGE CO
80034-0736
US

V. Phone/Fax

Practice location:
  • Phone: 307-682-1779
  • Fax: 307-682-1745
Mailing address:
  • Phone: 307-218-8223
  • Fax: 317-218-8224

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SHAUN ANDRIKOPOULOS
Title or Position: PARTNER
Credential:
Phone: 307-682-1779