Provider Demographics
NPI:1053338780
Name:DIAGNOSTIC RADIOLOGIC IMAGING PA
Entity type:Organization
Organization Name:DIAGNOSTIC RADIOLOGIC IMAGING PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LORI
Authorized Official - Middle Name:J
Authorized Official - Last Name:SPARTZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:507-372-2120
Mailing Address - Street 1:PO BOX 338
Mailing Address - Street 2:
Mailing Address - City:WORTHINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:56187
Mailing Address - Country:US
Mailing Address - Phone:507-372-2120
Mailing Address - Fax:507-372-4585
Practice Address - Street 1:1607 N MCMILLAN ST
Practice Address - Street 2:STE 1
Practice Address - City:WORTHINGTON
Practice Address - State:MN
Practice Address - Zip Code:56187
Practice Address - Country:US
Practice Address - Phone:507-372-2120
Practice Address - Fax:507-372-4585
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5452085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0144287Medicaid
MNC07286Medicare ID - Type Unspecified
IA0144287Medicaid