Provider Demographics
NPI:1487652608
Name:MOUNTAIN WEST RADIOLOGY, INC.
Entity Type:Organization
Organization Name:MOUNTAIN WEST RADIOLOGY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:WEBBER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:435-843-3600
Mailing Address - Street 1:PO BOX 1210
Mailing Address - Street 2:
Mailing Address - City:TOOELE
Mailing Address - State:UT
Mailing Address - Zip Code:84074-1210
Mailing Address - Country:US
Mailing Address - Phone:435-843-3646
Mailing Address - Fax:435-843-2590
Practice Address - Street 1:2055 N MAIN ST
Practice Address - Street 2:
Practice Address - City:TOOELE
Practice Address - State:UT
Practice Address - Zip Code:84074-9819
Practice Address - Country:US
Practice Address - Phone:435-843-3646
Practice Address - Fax:435-843-2590
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-12
Last Update Date:2010-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT20050632085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTDC9493Medicare PIN
UT000055939Medicare PIN