Provider Demographics
NPI:1518920206
Name:MEDICAL IMAGING NORTHWEST, LLP
Entity Type:Organization
Organization Name:MEDICAL IMAGING NORTHWEST, LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RADIOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:R
Authorized Official - Last Name:LEVINE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:253-841-4353
Mailing Address - Street 1:1201 PACIFIC AVE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98402-4301
Mailing Address - Country:US
Mailing Address - Phone:253-841-4353
Mailing Address - Fax:253-581-5698
Practice Address - Street 1:222 15TH AVE SE
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98372-3754
Practice Address - Country:US
Practice Address - Phone:253-841-4353
Practice Address - Fax:253-581-5698
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-11
Last Update Date:2011-06-08
Deactivation Date:2006-04-13
Deactivation Code:
Reactivation Date:2006-04-26
Provider Licenses
StateLicense IDTaxonomies
WAMD00011474174400000X
CAC27417174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL8194508Medicaid
WA74113OtherL&I
WAA08908Medicare UPIN
WA74113OtherL&I