Basic Information
| Provider Information | |||||||||
| NPI: | 1356340970 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OLYMPIA RADIOLOGISTS, P.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1879 | ||||||||
| Address2: | |||||||||
| City: | OLYMPIA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985071879 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3605703008 | ||||||||
| FaxNumber: | 3605703006 | ||||||||
| Practice Location | |||||||||
| Address1: | 3525 ENSIGN RD NE | ||||||||
| Address2: | SUITE B | ||||||||
| City: | OLYMPIA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985065065 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3605703008 | ||||||||
| FaxNumber: | 3605703006 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | HARRY | ||||||||
| AuthorizedOfficialFirstName: | JULIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRACTICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3605703008 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | WA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 113003 | 01 | WA | L&I NUMBER | OTHER | 7082654 | 05 | WA | MEDICAID |