Provider Demographics
NPI:1598921074
Name:PELLA IMAGING CONSULTANTS, INC
Entity Type:Organization
Organization Name:PELLA IMAGING CONSULTANTS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:LEE
Authorized Official - Middle Name:F
Authorized Official - Last Name:HENRY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:641-621-2347
Mailing Address - Street 1:166 4TH ST E
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55101-1421
Mailing Address - Country:US
Mailing Address - Phone:651-292-2000
Mailing Address - Fax:651-292-2178
Practice Address - Street 1:404 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:PELLA
Practice Address - State:IA
Practice Address - Zip Code:50219-1257
Practice Address - Country:US
Practice Address - Phone:641-621-2347
Practice Address - Fax:641-628-7241
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-04
Last Update Date:2010-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1598921074Medicaid
IA1598921074Medicaid