Provider Demographics
NPI:1356478499
Name:RADIOLOGY SPECIALISTS P A
Entity Type:Organization
Organization Name:RADIOLOGY SPECIALISTS P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:GENDREAU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-327-9277
Mailing Address - Street 1:PO BOX 1633
Mailing Address - Street 2:
Mailing Address - City:MERCER ISLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98040-1633
Mailing Address - Country:US
Mailing Address - Phone:425-327-9277
Mailing Address - Fax:206-275-3109
Practice Address - Street 1:4032 E MERCER WAY
Practice Address - Street 2:
Practice Address - City:MERCER ISLAND
Practice Address - State:WA
Practice Address - Zip Code:98040-3822
Practice Address - Country:US
Practice Address - Phone:253-572-2225
Practice Address - Fax:253-572-2356
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-27
Last Update Date:2015-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP000017102085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1120617Medicaid
F93574Medicare UPIN
WA8809177Medicare ID - Type Unspecified