Provider Demographics
NPI:1760636930
Name:MEDICAL IMAGING NORTHWEST - GOOD SAMARITAN HOSPITAL IMAGING ALLIANCE
Entity Type:Organization
Organization Name:MEDICAL IMAGING NORTHWEST - GOOD SAMARITAN HOSPITAL IMAGING ALLIANCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:P
Authorized Official - Last Name:SEILER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:253-761-4200
Mailing Address - Street 1:1304 FAWCETT AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98402-1900
Mailing Address - Country:US
Mailing Address - Phone:253-761-4200
Mailing Address - Fax:253-583-8630
Practice Address - Street 1:21110 SR 410 E
Practice Address - Street 2:#110
Practice Address - City:BONNEY LAKE
Practice Address - State:WA
Practice Address - Zip Code:98391-8457
Practice Address - Country:US
Practice Address - Phone:253-841-4353
Practice Address - Fax:253-583-8630
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-13
Last Update Date:2018-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
602760002261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology