Provider Demographics
NPI:1144650938
Name:DIAGNOSTIC RADIOLOGY PC VEIN CLINIC
Entity type:Organization
Organization Name:DIAGNOSTIC RADIOLOGY PC VEIN CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JO
Authorized Official - Middle Name:A
Authorized Official - Last Name:POHL
Authorized Official - Suffix:
Authorized Official - Credentials:CPC
Authorized Official - Phone:308-647-6444
Mailing Address - Street 1:PO BOX 3521
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68103-0521
Mailing Address - Country:US
Mailing Address - Phone:308-647-6444
Mailing Address - Fax:866-902-2445
Practice Address - Street 1:26136 US HIGHWAY 59
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:MO
Practice Address - Zip Code:64446-9105
Practice Address - Country:US
Practice Address - Phone:308-647-6444
Practice Address - Fax:866-902-2445
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DIAGNOSTIC RADIOLOGY PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-11-15
Last Update Date:2013-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOMA3807Medicare PIN