Provider Demographics
NPI:1922006519
Name:ADVANCED DIAGNOSTIC RADIOLOGY PC
Entity Type:Organization
Organization Name:ADVANCED DIAGNOSTIC RADIOLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:P
Authorized Official - Last Name:MORADIAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-557-0999
Mailing Address - Street 1:PO BOX 2537
Mailing Address - Street 2:
Mailing Address - City:WILLISTON
Mailing Address - State:ND
Mailing Address - Zip Code:58802-2537
Mailing Address - Country:US
Mailing Address - Phone:866-338-6472
Mailing Address - Fax:
Practice Address - Street 1:1301 15TH AVE W
Practice Address - Street 2:
Practice Address - City:WILLISTON
Practice Address - State:ND
Practice Address - Zip Code:58801-3821
Practice Address - Country:US
Practice Address - Phone:701-774-7401
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-08
Last Update Date:2008-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDIF - 8L493OtherBC NUMBER - IDAHO FALLS
IDPOC - 8L501OtherBC NUMBER FOR POCATELLO
ID807083700Medicaid
UT8M916OtherBC OF IDAHO
ID000010149528OtherBLUE SHIELD NUMBER
ND15040Medicaid
ID807083700Medicaid