Provider Demographics
NPI:1649556838
Name:BLACK ROCK ADVANCED MEDICAL IMAGING
Entity Type:Organization
Organization Name:BLACK ROCK ADVANCED MEDICAL IMAGING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:GREGORY
Authorized Official - Last Name:MURPHY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:307-358-6200
Mailing Address - Street 1:PO BOX 37
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:WY
Mailing Address - Zip Code:82633-0037
Mailing Address - Country:US
Mailing Address - Phone:307-358-6200
Mailing Address - Fax:307-358-3748
Practice Address - Street 1:620 4J CT
Practice Address - Street 2:UNIT C
Practice Address - City:GILLETTE
Practice Address - State:WY
Practice Address - Zip Code:82716-4130
Practice Address - Country:US
Practice Address - Phone:307-682-8228
Practice Address - Fax:307-682-8266
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-01
Last Update Date:2012-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
No293D00000XLaboratoriesPhysiological LaboratoryGroup - Single Specialty