Provider Demographics
NPI:1619070208
Name:SNAKE RIVER RADIOLOGY PC
Entity Type:Organization
Organization Name:SNAKE RIVER RADIOLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CORP SECRETARY
Authorized Official - Prefix:MRS
Authorized Official - First Name:JANET
Authorized Official - Middle Name:R
Authorized Official - Last Name:CEGNAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:541-889-9545
Mailing Address - Street 1:964 W IDAHO AVE
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:OR
Mailing Address - Zip Code:97914-2111
Mailing Address - Country:US
Mailing Address - Phone:541-889-9545
Mailing Address - Fax:541-889-8376
Practice Address - Street 1:964 W IDAHO AVE
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:OR
Practice Address - Zip Code:97914-2111
Practice Address - Country:US
Practice Address - Phone:541-889-9545
Practice Address - Fax:541-889-8376
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID80408077Medicaid
OR084934Medicaid
OR0000WFBWLMedicare ID - Type Unspecified