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General NPI Number Information
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NPI Number | 1780702993
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Entity Type | Organization
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Legal Business Name | DIAGNOSTIC RADIOLOGISTS, PC
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Dates
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Enumeration Date | 03/26/2007
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Last Update Date | 05/20/2019
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Provider Practice Location Address
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Address Line | 10123 SE MARKET ST
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City | PORTLAND
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State | OR
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Zip | 97216-2532
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Country | US
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Telephone | 503-251-6132
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 2097
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City | PORTLAND
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State | OR
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Zip | 97208-2097
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Country | US
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Telephone | 503-251-6132
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Fax | 503-251-6236
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Authorized Official
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Title or Position | PRESIDENT
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Name | JED RUSSELL PETERSON
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Credential | MD
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Telephone | 503-251-6132
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number |
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License Number State |
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