Basic Information
Provider Information | |||||||||
NPI: | 1811992670 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | VANCOUVER RADIOLOGISTS A PROFESSIONAL CORP | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | VANCOUVER RADIOLOGISTS, P.C. | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4201 N.E. 66TH AVE. | ||||||||
Address2: | SUITE 104 | ||||||||
City: | VANCOUVER | ||||||||
State: | WA | ||||||||
PostalCode: | 98661 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3602544914 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 4816 N.E. THURSTON WAY | ||||||||
Address2: | SUITE A | ||||||||
City: | VANCOUVER | ||||||||
State: | WA | ||||||||
PostalCode: | 98662 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3602544914 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/17/2005 | ||||||||
LastUpdateDate: | 04/09/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SCHROEDER | ||||||||
AuthorizedOfficialFirstName: | JOHN | ||||||||
AuthorizedOfficialMiddleName: | W. R. | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT / CEO | ||||||||
AuthorizedOfficialTelephone: | 3602544914 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X |   | OR | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X |   | WA | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
ID | Type | State | Issuer | Description | 7833502 | 05 | WA |   | MEDICAID |