Provider Demographics
NPI:1982722492
Name:AVALON RADIOLOGY INC
Entity Type:Organization
Organization Name:AVALON RADIOLOGY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:J
Authorized Official - Last Name:ROSE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-497-2500
Mailing Address - Street 1:202 MAPLEWOOD AVE
Mailing Address - Street 2:RADIOLOGY DEPARTMENT
Mailing Address - City:RONCEVERTE
Mailing Address - State:WV
Mailing Address - Zip Code:24970-1334
Mailing Address - Country:US
Mailing Address - Phone:304-497-2500
Mailing Address - Fax:
Practice Address - Street 1:202 MAPLEWOOD AVE
Practice Address - Street 2:RADIOLOGY DEPARTMENT
Practice Address - City:RONCEVERTE
Practice Address - State:WV
Practice Address - Zip Code:24970-1334
Practice Address - Country:US
Practice Address - Phone:304-497-2500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-26
Last Update Date:2007-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVWV 177112085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV17711OtherSTATE LICENSE
WV0120343000Medicaid
WV17711OtherSTATE LICENSE
F83747Medicare UPIN