Provider Demographics
NPI:1558436451
Name:PENINSULA IMAGING PLLC
Entity Type:Organization
Organization Name:PENINSULA IMAGING PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:SCOT
Authorized Official - Last Name:FISHMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:360-582-0590
Mailing Address - Street 1:PO BOX 24322
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-0322
Mailing Address - Country:US
Mailing Address - Phone:360-582-0590
Mailing Address - Fax:360-582-0172
Practice Address - Street 1:500 W FIR ST
Practice Address - Street 2:SUITE C
Practice Address - City:SEQUIM
Practice Address - State:WA
Practice Address - Zip Code:98382-3201
Practice Address - Country:US
Practice Address - Phone:360-582-0590
Practice Address - Fax:360-582-0172
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-24
Last Update Date:2008-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00029650261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8856298Medicare PIN
WAF38099Medicare UPIN