MEDICARE: HEALTHEAST MEDICAL IMAGING LLC

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	2085R0202X	Diagnostic Radiology Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1316965064
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HEALTHEAST MEDICAL IMAGING LLC

Provider Business Mailing Address
First Line	:	3640 TALMAGE CIRCLE
Second Line	:	STE 100
City	:	VADNAIS HEIGHTS
State	:	MN
Zip	:	55110
Country	:	US
Telephone Number	:	651-426-7226
Fax Number	:	651-426-7235

Provider Business Practice Location Address
First Line	:	3640 TALMAGE CIRCLE
Second Line	:	STE 100
City	:	VADNAIS HEIGHTS
State	:	MN
Zip	:	55110
Country	:	US
Telephone Number	:	651-426-7226
Fax Number	:	651-426-7235

Authorized Official
Title or Position	:	CFO
Name	:	DOUG DAVENPORT
Credential	:
Telephone Number	:	651-232-2250

Provider Enumeration Date	:	07/18/2006
Last Update Date	:	05/20/2015

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