Provider Demographics
NPI:1487643904
Name:NORTHERN UTAH IMAGING LLC
Entity Type:Organization
Organization Name:NORTHERN UTAH IMAGING LLC
Other - Org Name:MILLCREEK IMAGING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:IMAGING & ONCOLOGY MANAGED CARE
Authorized Official - Prefix:MR
Authorized Official - First Name:LAVELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:HARDIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-372-5441
Mailing Address - Street 1:3738 S 900 E
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84106-1913
Mailing Address - Country:US
Mailing Address - Phone:801-313-1955
Mailing Address - Fax:801-313-1965
Practice Address - Street 1:3738 S 900 E
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84106-1913
Practice Address - Country:US
Practice Address - Phone:801-313-1955
Practice Address - Fax:801-313-1965
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-18
Last Update Date:2010-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTP00141132OtherRR MEDICARE
UTP00141132OtherRR MEDICARE
UTOOOO90762Medicare PIN