Provider Demographics
NPI:1417935321
Name:REGIONAL DIAGNOSTIC RADIOLOGY
Entity Type:Organization
Organization Name:REGIONAL DIAGNOSTIC RADIOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:E
Authorized Official - Last Name:HONDL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:320-257-7794
Mailing Address - Street 1:PO BOX 7366
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56302-7366
Mailing Address - Country:US
Mailing Address - Phone:320-257-5595
Mailing Address - Fax:320-257-5596
Practice Address - Street 1:1990 CONNECTICUT AVE S
Practice Address - Street 2:
Practice Address - City:SARTELL
Practice Address - State:MN
Practice Address - Zip Code:56377-2554
Practice Address - Country:US
Practice Address - Phone:320-257-5595
Practice Address - Fax:320-257-5596
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-03
Last Update Date:2014-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN55432CLOtherBLUE CROSS BLUE SHIELD
MN775213000Medicaid
MNC07651Medicare UPIN