Provider Demographics
NPI:1194867887
Name:NORTHWEST RADIOLOGY GROUP LLC
Entity Type:Organization
Organization Name:NORTHWEST RADIOLOGY GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER CEO
Authorized Official - Prefix:
Authorized Official - First Name:NELSON
Authorized Official - Middle Name:R
Authorized Official - Last Name:GOEHLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-413-8301
Mailing Address - Street 1:500 LILLY RD NE
Mailing Address - Street 2:SUITE 160
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98506-5195
Mailing Address - Country:US
Mailing Address - Phone:360-413-8307
Mailing Address - Fax:360-413-8805
Practice Address - Street 1:500 LILLY RD NE
Practice Address - Street 2:SUITE 160
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-5195
Practice Address - Country:US
Practice Address - Phone:360-413-8307
Practice Address - Fax:360-413-8805
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8801573Medicare ID - Type Unspecified