Provider Demographics
NPI:1073777264
Name:NORTHSTAR IMAGING INC
Entity Type:Organization
Organization Name:NORTHSTAR IMAGING INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:PENNEBAKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:775-829-9880
Mailing Address - Street 1:6490 S MCCARRAN BLVD STE 22
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89509-6123
Mailing Address - Country:US
Mailing Address - Phone:775-829-9880
Mailing Address - Fax:775-829-9876
Practice Address - Street 1:25 MCCABE DR
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89511-5991
Practice Address - Country:US
Practice Address - Phone:775-852-5444
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-16
Last Update Date:2008-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVV36907Medicare PIN