Provider Demographics
NPI:1376536763
Name:YELLOWSTONE RADIOLOGY PC
Entity Type:Organization
Organization Name:YELLOWSTONE RADIOLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DELEGATED OFFICIAL
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:H
Authorized Official - Last Name:CROSS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:307-578-2582
Mailing Address - Street 1:PO BOX 1829
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83816-1829
Mailing Address - Country:US
Mailing Address - Phone:800-667-9334
Mailing Address - Fax:208-664-2341
Practice Address - Street 1:707 SHERIDAN AVE
Practice Address - Street 2:
Practice Address - City:CODY
Practice Address - State:WY
Practice Address - Zip Code:82414-3409
Practice Address - Country:US
Practice Address - Phone:208-667-9334
Practice Address - Fax:208-664-2341
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-31
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYDC9336OtherRR MEDICARE
WY120635400Medicaid