Provider Demographics
NPI:1952344137
Name:SWEETWATER RADIOLOGY, PC
Entity Type:Organization
Organization Name:SWEETWATER RADIOLOGY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:HOLTAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:623-399-3266
Mailing Address - Street 1:PO BOX 2146
Mailing Address - Street 2:
Mailing Address - City:ROCK SPRINGS
Mailing Address - State:WY
Mailing Address - Zip Code:82902-2146
Mailing Address - Country:US
Mailing Address - Phone:405-947-5557
Mailing Address - Fax:405-948-6507
Practice Address - Street 1:1400 UINTA DR
Practice Address - Street 2:
Practice Address - City:GREEN RIVER
Practice Address - State:WY
Practice Address - Zip Code:82935-5060
Practice Address - Country:US
Practice Address - Phone:307-872-4541
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-14
Last Update Date:2011-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY00983001OtherBCBS OF WY
WY106271900Medicaid
WY106271900Medicaid
CO3010Medicare PIN