Provider Demographics
NPI:1730393224
Name:GENERAL RADIOLOGY PC
Entity type:Organization
Organization Name:GENERAL RADIOLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT GENERAL RADIOLOGY
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:CHRISTIAN
Authorized Official - Last Name:JOHANNSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:402-721-4866
Mailing Address - Street 1:415 EAST 23RD ST
Mailing Address - Street 2:STE 210
Mailing Address - City:FREMONT
Mailing Address - State:NE
Mailing Address - Zip Code:68025-2393
Mailing Address - Country:US
Mailing Address - Phone:402-721-4866
Mailing Address - Fax:402-721-3229
Practice Address - Street 1:450 E 23RD ST
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:NE
Practice Address - Zip Code:68025
Practice Address - Country:US
Practice Address - Phone:402-721-3070
Practice Address - Fax:402-727-3513
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-10
Last Update Date:2008-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE092262Medicare PIN