Healthcare Provider Details

I. General information

NPI: 1952344137
Provider Name (Legal Business Name): SWEETWATER RADIOLOGY, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 08/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 UINTA DR
GREEN RIVER WY
82935-5060
US

IV. Provider business mailing address

PO BOX 2146
ROCK SPRINGS WY
82902-2146
US

V. Phone/Fax

Practice location:
  • Phone: 307-872-4541
  • Fax:
Mailing address:
  • Phone: 405-947-5557
  • Fax: 405-948-6507

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. BRIAN A HOLTAN
Title or Position: PRESIDENT
Credential: MD
Phone: 623-399-3266