Provider Demographics
NPI:1659580116
Name:PACIFIC NORTHWEST RADIOLOGY
Entity Type:Organization
Organization Name:PACIFIC NORTHWEST RADIOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:BURT
Authorized Official - Middle Name:J
Authorized Official - Last Name:LOESSBERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-687-7134
Mailing Address - Street 1:PO BOX 26570
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93729-6570
Mailing Address - Country:US
Mailing Address - Phone:541-687-7134
Mailing Address - Fax:
Practice Address - Street 1:1915 E REZANOF DR
Practice Address - Street 2:
Practice Address - City:KODIAK
Practice Address - State:AK
Practice Address - Zip Code:99615-6602
Practice Address - Country:US
Practice Address - Phone:907-486-3281
Practice Address - Fax:907-486-2336
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK3143442085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty