Basic Information
| Provider Information | |||||||||
| NPI: | 1184869901 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RADIOLOGY IMAGING OF NEBRASKA, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10800 E GEDDES AVE STE 300 | ||||||||
| Address2: | |||||||||
| City: | ENGLEWOOD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801123895 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037619190 | ||||||||
| FaxNumber: | 7208744462 | ||||||||
| Practice Location | |||||||||
| Address1: | 4021 AVENUE B | ||||||||
| Address2: | |||||||||
| City: | SCOTTSBLUFF | ||||||||
| State: | NE | ||||||||
| PostalCode: | 693614602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3086353711 | ||||||||
| FaxNumber: | 3036301120 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/08/2008 | ||||||||
| LastUpdateDate: | 03/19/2021 | ||||||||
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| AuthorizedOfficialLastName: | GRILLO | ||||||||
| AuthorizedOfficialFirstName: | GRACEANN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING SUPERVISOR | ||||||||
| AuthorizedOfficialTelephone: | 7204933716 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 03/19/2021 | ||||||||
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 | 1184869901 | 05 | MO | MEDICAID | 10025709000 | 05 | NE | MEDICAID | 1184869901 | 05 | IA | MEDICAID | 100262777-00 | 05 | NE | MEDICAID | 100262778-00 | 05 | NE | MEDICAID |