1336716075 NPI number — PROFESSIONAL PORTABLE RADIOLOGIC SERVICES, INC.

Table of content: (NPI 1336716075)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336716075 NPI number — PROFESSIONAL PORTABLE RADIOLOGIC SERVICES, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROFESSIONAL PORTABLE RADIOLOGIC SERVICES, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
PROFESSIONAL PORTABLE X-RAY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1336716075
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/08/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
755 CLIFF RD E
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BURNSVILLE
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55337-1545
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
952-915-9779
Provider Business Mailing Address Fax Number:
952-915-9597

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
540 STATE ROUTE 10 STE 1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RANDOLPH
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07869-2033
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
866-895-2119
Provider Business Practice Location Address Fax Number:
952-915-9597
Provider Enumeration Date:
06/10/2021

Additional Information

Authorized Official

Authorized Official Last Name:
JOHNSON
Authorized Official First Name:
BRUCE
Authorized Official Middle Name:
ALLEN
Authorized Official Title or Position:
VP - AO
Authorized Official Telephone Number:
303-589-4149

Provider Taxonomy Codes

  • Taxonomy code: 335V00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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