MEDICARE: MOUNTAIN RADIOLOGY, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2085R0204X	Vascular & Interventional Radiology Physician
2	2085R0202X	Diagnostic Radiology Physician

General Provider Information

NPI Number	:	1083209654
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOUNTAIN RADIOLOGY, INC

Provider Business Mailing Address
First Line	:	PO BOX 85500
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60689-5500
Country	:	US
Telephone Number	:	970-900-6856
Fax Number	:

Provider Business Practice Location Address
First Line	:	9 HAWK RIDGE DR
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89135-7864
Country	:	US
Telephone Number	:	970-945-7564
Fax Number	:

Authorized Official
Title or Position	:	AO
Name	:	KAREN MARIE VAUGHN
Credential	:
Telephone Number	:	629-317-1465

Provider Enumeration Date	:	03/05/2021
Last Update Date	:	03/26/2026

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