Provider Demographics
NPI:1053368563
Name:DIAGNOSTIC RADIOLOGISTS PC
Entity type:Organization
Organization Name:DIAGNOSTIC RADIOLOGISTS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JED
Authorized Official - Middle Name:RUSSELL
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:503-251-6132
Mailing Address - Street 1:PO BOX 16961
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97292-0961
Mailing Address - Country:US
Mailing Address - Phone:035-251-6855
Mailing Address - Fax:503-251-6136
Practice Address - Street 1:10123 SE MARKET
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97216
Practice Address - Country:US
Practice Address - Phone:503-251-6132
Practice Address - Fax:503-251-6136
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-28
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
HIH110076Medicaid
OR064972Medicaid
WA7805609Medicaid
ORC01682Medicare PIN