Provider Demographics
NPI:1619970910
Name:PROACTIVE IMAGING LLC
Entity Type:Organization
Organization Name:PROACTIVE IMAGING LLC
Other - Org Name:MINNESOTA RADIOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ANGEL
Authorized Official - Middle Name:L
Authorized Official - Last Name:SOTO
Authorized Official - Suffix:
Authorized Official - Credentials:PRESIDENT
Authorized Official - Phone:954-559-2421
Mailing Address - Street 1:4000 W 76TH ST
Mailing Address - Street 2:STE 100
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-5104
Mailing Address - Country:US
Mailing Address - Phone:952-853-7226
Mailing Address - Fax:952-831-7555
Practice Address - Street 1:4000 W 76TH ST
Practice Address - Street 2:STE 100
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-5104
Practice Address - Country:US
Practice Address - Phone:952-853-7226
Practice Address - Fax:952-831-7555
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-31
Last Update Date:2008-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5402085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN22030077OtherOFFICE OF WORK COMP.
MNP00053758OtherMEDICARE RAILROAD
MN22030077OtherOFFICE OF WORK COMP.