Provider Demographics
NPI:1497704860
Name:DEACONESS INTERCITY IMAGING,LLC
Entity Type:Organization
Organization Name:DEACONESS INTERCITY IMAGING,LLC
Other - Org Name:ADVANCED MEDICAL IMAGING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BRANDEE
Authorized Official - Middle Name:
Authorized Official - Last Name:DESLAURIERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-587-8631
Mailing Address - Street 1:1648 ELLIS ST STE 201
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59715-8811
Mailing Address - Country:US
Mailing Address - Phone:406-587-8631
Mailing Address - Fax:406-587-1343
Practice Address - Street 1:905 HIGHLAND BLVD
Practice Address - Street 2:SUITE 4100
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-6902
Practice Address - Country:US
Practice Address - Phone:406-556-5200
Practice Address - Fax:406-556-5205
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-10
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261Q00000X
MT7873261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty
No261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT99988OtherBC BS GROUP NUMBER
MT000084790Medicare PIN