MEDICARE: BDC RADIOLOGY INC PS

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	261Q00000X	Clinic/Center	602300908	WA

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	:	1811005861
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BDC RADIOLOGY INC PS

Provider Business Mailing Address
First Line	:	1268 E MAIN ST
Second Line	:	SUITE 1
City	:	AUBURN
State	:	WA
Zip	:	98002-5748
Country	:	US
Telephone Number	:	253-735-1991
Fax Number	:	253-735-8837

Provider Business Practice Location Address
First Line	:	1268 E MAIN ST
Second Line	:	SUITE 1
City	:	AUBURN
State	:	WA
Zip	:	98002-5748
Country	:	US
Telephone Number	:	253-735-1991
Fax Number	:	253-735-8837

Authorized Official
Title or Position	:	PRESIDENT
Name	:	JOHN T BLACKWELDER
Credential	:	MD
Telephone Number	:	253-735-1991

Provider Enumeration Date	:	08/29/2006
Last Update Date	:	07/17/2014

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