Provider Demographics
NPI:1346321155
Name:BLUE MOUNTAIN DIAGNOSTIC IMAGING, INC
Entity Type:Organization
Organization Name:BLUE MOUNTAIN DIAGNOSTIC IMAGING, INC
Other - Org Name:BLUE MOUNTAIN DIAGNOSTIC IMAGING
Other - Org Type:Other Name
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LYNNE
Authorized Official - Middle Name:
Authorized Official - Last Name:FITZGERALD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-276-2431
Mailing Address - Street 1:1100 SOUTHGATE
Mailing Address - Street 2:SUITE 7
Mailing Address - City:PENDLETON
Mailing Address - State:OR
Mailing Address - Zip Code:97801-3974
Mailing Address - Country:US
Mailing Address - Phone:541-276-2431
Mailing Address - Fax:541-276-1947
Practice Address - Street 1:1100 SOUTHGATE
Practice Address - Street 2:SUITE 7
Practice Address - City:PENDLETON
Practice Address - State:OR
Practice Address - Zip Code:97801-3974
Practice Address - Country:US
Practice Address - Phone:541-276-2431
Practice Address - Fax:541-276-1947
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-18
Last Update Date:2012-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
R0000WCGHXMedicare ID - Type Unspecified