Basic Information
| Provider Information | |||||||||
| NPI: | 1639653017 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RADIA IMAGING CENTER HOLDINGS LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 19020 33RD AVE W STE 210 | ||||||||
| Address2: | |||||||||
| City: | LYNNWOOD | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980364748 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4255631508 | ||||||||
| FaxNumber: | 4255631501 | ||||||||
| Practice Location | |||||||||
| Address1: | 1229 MADISON ST STE 900 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981041391 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2062926233 | ||||||||
| FaxNumber: | 2062927764 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2018 | ||||||||
| LastUpdateDate: | 09/20/2018 | ||||||||
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| AuthorizedOfficialLastName: | KEOGH | ||||||||
| AuthorizedOfficialFirstName: | BART | ||||||||
| AuthorizedOfficialMiddleName: | P. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4255631500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | RADIA INC PS | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.