Provider Demographics
NPI:1033144951
Name:OUTPATIENT IMAGING
Entity Type:Organization
Organization Name:OUTPATIENT IMAGING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:MATTHIAS
Authorized Official - Last Name:BOUSHKA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:505-532-8800
Mailing Address - Street 1:3850 FOOTHILLS RD
Mailing Address - Street 2:STE. 9
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-4632
Mailing Address - Country:US
Mailing Address - Phone:505-532-8800
Mailing Address - Fax:505-532-5920
Practice Address - Street 1:6065 MONTANA AVE
Practice Address - Street 2:STE. A-6
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79925-1835
Practice Address - Country:US
Practice Address - Phone:505-532-8800
Practice Address - Fax:505-532-5920
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-11
Last Update Date:2007-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ0750174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
H09636Medicare UPIN