Basic Information
| Provider Information | |||||||||
| NPI: | 1487606026 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | J PAUL WIESNER & ASSOCIATES CHARTERED | ||||||||
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| OtherOrganizationName: | RADIOLOGY ASSOCIATES OF NEVADA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 30077 | ||||||||
| Address2: | DEPT 305 | ||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841300077 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8558654435 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5495 S RAINBOW BLVD STE 203 | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891181873 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7024770772 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2006 | ||||||||
| LastUpdateDate: | 10/30/2019 | ||||||||
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| AuthorizedOfficialLastName: | SOGGE | ||||||||
| AuthorizedOfficialFirstName: | STEVEN | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7024770772 | ||||||||
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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 | 2085N0700X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology | 2085R0202X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | NV4864 | 01 | NV | BCBS NV | OTHER | 200290100 | 05 | NV | MEDICAID |