Provider Demographics
NPI:1497051320
Name:NORTHWEST DIAGNOSTIC SERVICES
Entity Type:Organization
Organization Name:NORTHWEST DIAGNOSTIC SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXCECUTIVE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JANET
Authorized Official - Middle Name:
Authorized Official - Last Name:HETHERINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-622-6088
Mailing Address - Street 1:2728 W MAIN ST
Mailing Address - Street 2:SUITE 121
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97501-2499
Mailing Address - Country:US
Mailing Address - Phone:541-622-6088
Mailing Address - Fax:541-622-6090
Practice Address - Street 1:2728 W MAIN ST
Practice Address - Street 2:SUITE 121
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97501-2499
Practice Address - Country:US
Practice Address - Phone:541-622-6088
Practice Address - Fax:541-622-6090
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-10
Last Update Date:2013-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR12-35846261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR163709OtherMEDICARE PTAN