Basic Information
| Provider Information | |||||||||
| NPI: | 1003851841 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CENTRAL DAKOTA RADIOLOGISTS PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 810 E ROSSER AVE STE 201 | ||||||||
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| City: | BISMARCK | ||||||||
| State: | ND | ||||||||
| PostalCode: | 585014463 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8666075479 | ||||||||
| FaxNumber: | 9207390124 | ||||||||
| Practice Location | |||||||||
| Address1: | 900 E BROADWAY AVE | ||||||||
| Address2: | |||||||||
| City: | BISMARCK | ||||||||
| State: | ND | ||||||||
| PostalCode: | 585014520 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7015307000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2006 | ||||||||
| LastUpdateDate: | 01/23/2008 | ||||||||
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| AuthorizedOfficialLastName: | STONE | ||||||||
| AuthorizedOfficialFirstName: | MATTHEW | ||||||||
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| AuthorizedOfficialTitleorPosition: | SECRETARY/TREASURER | ||||||||
| AuthorizedOfficialTelephone: | 7015308575 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 11952 | 05 | ND | MEDICAID |