MEDICARE: ADVANCED DIAGNOSTIC RADIOLOGY PC

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	IF - 8L493	OTHER	ID	BC NUMBER - IDAHO FALLS
2	POC - 8L501	OTHER	ID	BC NUMBER FOR POCATELLO
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	8M916	OTHER	UT	BC OF IDAHO
5	000010149528	OTHER	ID	BLUE SHIELD NUMBER
6	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1922006519
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ADVANCED DIAGNOSTIC RADIOLOGY PC

Provider Business Mailing Address
First Line	:	PO BOX 2537
Second Line	:
City	:	WILLISTON
State	:	ND
Zip	:	58802-2537
Country	:	US
Telephone Number	:	866-338-6472
Fax Number	:

Provider Business Practice Location Address
First Line	:	1301 15TH AVE W
Second Line	:
City	:	WILLISTON
State	:	ND
Zip	:	58801-3821
Country	:	US
Telephone Number	:	701-774-7401
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. GLENN P MORADIAN
Credential	:	MD
Telephone Number	:	208-557-0999

Provider Enumeration Date	:	07/08/2005
Last Update Date	:	10/17/2008

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