Basic Information
| Provider Information | |||||||||
| NPI: | 1326373713 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MERCER ISLAND MEDICAL IMAGING, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2135 | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984012135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2537614200 | ||||||||
| FaxNumber: | 2533833553 | ||||||||
| Practice Location | |||||||||
| Address1: | 9655 SE 36TH ST | ||||||||
| Address2: | SUITE 107 | ||||||||
| City: | MERCER ISLAND | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980403798 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2537614200 | ||||||||
| FaxNumber: | 2533833553 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2009 | ||||||||
| LastUpdateDate: | 01/19/2011 | ||||||||
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| AuthorizedOfficialLastName: | DWIGHT | ||||||||
| AuthorizedOfficialFirstName: | CHRISTINE | ||||||||
| AuthorizedOfficialMiddleName: | E. | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF OPERATIONS OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2537614200 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 0028ME | 01 | WA | REGENCE | OTHER | O255941 | 01 | WA | LABOR & INDUSTRIES, CRIME VICTIMS COMPENSATION | OTHER | G8886633 | 01 | WA | PTAN | OTHER | 7148976 | 05 | WA | MEDICAID |