=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548413131
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PREMIER DIAGONSTIC IMAGING, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/28/2008
-----------------------------------------------------
Last Update Date | 10/28/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12800 HIGHWAY 55
-----------------------------------------------------
City | PLYMOUTH
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55441-3840
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 763-746-8001
-----------------------------------------------------
Fax | 763-746-8004
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12800 HIGHWAY 55
-----------------------------------------------------
City | PLYMOUTH
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55441-3840
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 763-746-8001
-----------------------------------------------------
Fax | 763-746-8004
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | KIM ALGOO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 763-746-8001
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------