Provider Demographics
NPI:1477788644
Name:RURAL RADIOLOGY ASSOCIATES TAOS
Entity type:Organization
Organization Name:RURAL RADIOLOGY ASSOCIATES TAOS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:575-758-8883
Mailing Address - Street 1:12687 W CEDAR DR
Mailing Address - Street 2:200
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80228-2014
Mailing Address - Country:US
Mailing Address - Phone:303-468-1395
Mailing Address - Fax:303-468-1394
Practice Address - Street 1:1397 WEIMAR RD
Practice Address - Street 2:
Practice Address - City:TAOS
Practice Address - State:NM
Practice Address - Zip Code:87571-6253
Practice Address - Country:US
Practice Address - Phone:575-758-8883
Practice Address - Fax:303-468-1394
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-18
Last Update Date:2019-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM64108236Medicaid