Provider Demographics
NPI:1649242819
Name:TANASBOURNE RADIOLOGY
Entity Type:Organization
Organization Name:TANASBOURNE RADIOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:S
Authorized Official - Last Name:PUTNAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:503-292-9108
Mailing Address - Street 1:PO BOX 25184
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97298-0184
Mailing Address - Country:US
Mailing Address - Phone:503-292-9108
Mailing Address - Fax:503-292-0346
Practice Address - Street 1:1881 NW 185TH AVE
Practice Address - Street 2:
Practice Address - City:ALOHA
Practice Address - State:OR
Practice Address - Zip Code:97006
Practice Address - Country:US
Practice Address - Phone:503-292-9108
Practice Address - Fax:503-292-0346
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-02
Last Update Date:2007-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR071303Medicaid
OR071303Medicaid