Provider Demographics
NPI:1356390736
Name:INTERCITY RADIOLOGY, PC
Entity type:Organization
Organization Name:INTERCITY RADIOLOGY, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANGER
Authorized Official - Prefix:
Authorized Official - First Name:JESSICALEE
Authorized Official - Middle Name:
Authorized Official - Last Name:FANDRICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-587-8631
Mailing Address - Street 1:1648 ELLIS ST STE 201
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59715-8811
Mailing Address - Country:US
Mailing Address - Phone:406-587-8631
Mailing Address - Fax:406-587-1343
Practice Address - Street 1:1648 ELLIS ST STE 201
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-8811
Practice Address - Country:US
Practice Address - Phone:406-587-8631
Practice Address - Fax:406-587-1343
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-10
Last Update Date:2020-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT001027OtherBC BS
MT001027OtherBC BS