Provider Demographics
NPI:1164493334
Name:PHOENIX RADIOLOGY, PLLC
Entity Type:Organization
Organization Name:PHOENIX RADIOLOGY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:W
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-743-4393
Mailing Address - Street 1:531 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-2450
Mailing Address - Country:US
Mailing Address - Phone:208-743-4393
Mailing Address - Fax:208-743-4214
Practice Address - Street 1:415 6TH ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-2431
Practice Address - Country:US
Practice Address - Phone:208-799-5335
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Not Answered2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC3860OtherRAILROAD MEDICARE
WA0192979OtherLABOR & INDUSTRIES
ID000010148406OtherREGENCE BS OF IDAHO
ID8J679OtherBLUE CROSS OF IDAHO
WA7124605Medicaid
WA0192979OtherLABOR & INDUSTRIES