Basic Information
| Provider Information | |||||||||
| NPI: | 1588904338 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TRA-MINW, PS | ||||||||
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| OtherOrganizationName: | TACOMA RADIOLOGICAL ASSOCIATES, P.S. | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3656 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981243656 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8662319211 | ||||||||
| FaxNumber: | 8005084751 | ||||||||
| Practice Location | |||||||||
| Address1: | 1601 SE COURT AVE | ||||||||
| Address2: | DEPARTMENT OF RADIOLOGY | ||||||||
| City: | PENDLETON | ||||||||
| State: | OR | ||||||||
| PostalCode: | 978013217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2537614200 | ||||||||
| FaxNumber: | 2533830730 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2013 | ||||||||
| LastUpdateDate: | 09/11/2020 | ||||||||
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| AuthorizedOfficialLastName: | EPSHTEYN | ||||||||
| AuthorizedOfficialFirstName: | VICTORIA | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR OF FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 2537614200 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 09/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207U00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Nuclear Medicine | 2085N0700X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology | 2085P0229X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Pediatric Radiology | 2085R0204X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2085U0001X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Ultrasound | 2085R0202X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 500663945 | 05 | OR | MEDICAID |