Provider Demographics
NPI:1720059264
Name:MIDWEST RADIOLOGY OUTPATIENT IMAGING, LLC
Entity Type:Organization
Organization Name:MIDWEST RADIOLOGY OUTPATIENT IMAGING, LLC
Other - Org Name:MIDWEST RADIOLOGY OUTPATIENT IMAGING, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SEE
Authorized Official - Middle Name:
Authorized Official - Last Name:YANG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-292-2013
Mailing Address - Street 1:2355 HWY 36 W.
Mailing Address - Street 2:STE. 100
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113-3905
Mailing Address - Country:US
Mailing Address - Phone:651-292-2000
Mailing Address - Fax:
Practice Address - Street 1:250 THOMPSON ST
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102-2370
Practice Address - Country:US
Practice Address - Phone:651-292-2000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-01
Last Update Date:2021-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN485512400Medicaid
MNC02661Medicare ID - Type Unspecified