Provider Demographics
NPI:1225018146
Name:WHITE MOUNTAIN RADIOLOGY
Entity Type:Organization
Organization Name:WHITE MOUNTAIN RADIOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NPI
Authorized Official - Prefix:
Authorized Official - First Name:EDGAR
Authorized Official - Middle Name:JAY
Authorized Official - Last Name:PRINGLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-537-6338
Mailing Address - Street 1:PO BOX 591
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31902-0500
Mailing Address - Country:US
Mailing Address - Phone:706-653-1102
Mailing Address - Fax:
Practice Address - Street 1:2200 E SHOW LOW LAKE RD
Practice Address - Street 2:
Practice Address - City:SHOW LOW
Practice Address - State:AZ
Practice Address - Zip Code:85901-7881
Practice Address - Country:US
Practice Address - Phone:928-537-6338
Practice Address - Fax:928-532-5947
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-18
Last Update Date:2009-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZWMBLJMedicare PIN