Provider Demographics
NPI:1881651289
Name:CORVALLIS RADIOLOGY PC
Entity Type:Organization
Organization Name:CORVALLIS RADIOLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:LEILA
Authorized Official - Middle Name:
Authorized Official - Last Name:BENDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-452-8002
Mailing Address - Street 1:PO BOX 1615
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47706-0017
Mailing Address - Country:US
Mailing Address - Phone:541-452-8002
Mailing Address - Fax:541-758-3713
Practice Address - Street 1:777 NW 9TH ST STE 210C
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-6169
Practice Address - Country:US
Practice Address - Phone:541-452-8002
Practice Address - Fax:541-758-3713
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-28
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR181442085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR142612Medicaid
WAG8864007Medicare PIN
ORR0000WCGDBMedicare PIN