Provider Demographics
NPI:1124031489
Name:PLAZA RADIOLOGY INC
Entity Type:Organization
Organization Name:PLAZA RADIOLOGY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER OPERATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:FRIEST
Authorized Official - Suffix:
Authorized Official - Credentials:RTR
Authorized Official - Phone:360-676-4190
Mailing Address - Street 1:PO BOX 2478
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98227-2478
Mailing Address - Country:US
Mailing Address - Phone:360-676-8476
Mailing Address - Fax:360-738-1946
Practice Address - Street 1:3015 SQUALICUM PARKWAY
Practice Address - Street 2:SUITE 130
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-1906
Practice Address - Country:US
Practice Address - Phone:360-676-4190
Practice Address - Fax:360-676-4349
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WART000000482085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7131832Medicaid
X15014Medicare UPIN
WA7131832Medicaid