Provider Demographics
NPI:1942375852
Name:WILLISTON RADIOLOGY CONSULTANTS PC
Entity Type:Organization
Organization Name:WILLISTON RADIOLOGY CONSULTANTS PC
Other - Org Name:FAIRLIGHT MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LESZEK
Authorized Official - Middle Name:J
Authorized Official - Last Name:JASZCZAK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:701-577-6337
Mailing Address - Street 1:PO BOX 1148
Mailing Address - Street 2:
Mailing Address - City:WILLISTON
Mailing Address - State:ND
Mailing Address - Zip Code:58802-1148
Mailing Address - Country:US
Mailing Address - Phone:701-577-4867
Mailing Address - Fax:701-577-4867
Practice Address - Street 1:3 4TH ST E
Practice Address - Street 2:SUITE 201
Practice Address - City:WILLISTON
Practice Address - State:ND
Practice Address - Zip Code:58801-5350
Practice Address - Country:US
Practice Address - Phone:701-577-4867
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-24
Last Update Date:2020-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND7782174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NDG56661Medicare UPIN
ND15191Medicare ID - Type Unspecified