Provider Demographics
NPI:1134196306
Name:NORTHEAST MEDICAL IMAGING PC
Entity type:Organization
Organization Name:NORTHEAST MEDICAL IMAGING PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PART OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:
Authorized Official - Last Name:ECKSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:402-644-7679
Mailing Address - Street 1:2700 W NORFOLK AVE
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:NE
Mailing Address - Zip Code:68701-4438
Mailing Address - Country:US
Mailing Address - Phone:402-644-7679
Mailing Address - Fax:
Practice Address - Street 1:2700 W NORFOLK AVE
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:NE
Practice Address - Zip Code:68701-4438
Practice Address - Country:US
Practice Address - Phone:402-644-7679
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-07
Last Update Date:2010-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE=========13Medicaid
098566Medicare ID - Type UnspecifiedGROUP NUMBER