Provider Demographics
NPI:1114969532
Name:MCKENZIE MEDICAL IMAGING PC
Entity Type:Organization
Organization Name:MCKENZIE MEDICAL IMAGING PC
Other - Org Name:WILLAMETTE VALLEY MAMMOGRAPHY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:VICKI
Authorized Official - Middle Name:L
Authorized Official - Last Name:BRIDGES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-726-4699
Mailing Address - Street 1:960 N 16TH ST
Mailing Address - Street 2:SUITE 105
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OR
Mailing Address - Zip Code:97477-4175
Mailing Address - Country:US
Mailing Address - Phone:541-726-4699
Mailing Address - Fax:541-744-6069
Practice Address - Street 1:960 N 16TH ST
Practice Address - Street 2:SUITE 105
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97477-4175
Practice Address - Country:US
Practice Address - Phone:541-726-4699
Practice Address - Fax:541-744-6069
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-11
Last Update Date:2009-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORC03559OtherRAILROAD MEDICARE
OR018382Medicaid
ORR0000WCGGVMedicare PIN