Provider Demographics
NPI:1184242521
Name:ELEVATION MEDICAL IMAGING EVANSTON
Entity type:Organization
Organization Name:ELEVATION MEDICAL IMAGING EVANSTON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:SHAUN
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDRIKOPOULOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-444-4215
Mailing Address - Street 1:PO BOX 2393
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83403-2393
Mailing Address - Country:US
Mailing Address - Phone:800-338-5378
Mailing Address - Fax:208-523-8978
Practice Address - Street 1:1485 STATE HIGHWAY 150 S
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:WY
Practice Address - Zip Code:82930-5344
Practice Address - Country:US
Practice Address - Phone:307-444-4215
Practice Address - Fax:307-444-4219
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-13
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
No261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)