Provider Demographics
NPI:1104098441
Name:NORTHWEST RADIOLOGY
Entity type:Organization
Organization Name:NORTHWEST RADIOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:BANCROFT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:401-568-7661
Mailing Address - Street 1:36 BRIDGE WAY
Mailing Address - Street 2:
Mailing Address - City:PASCOAG
Mailing Address - State:RI
Mailing Address - Zip Code:02859-3131
Mailing Address - Country:US
Mailing Address - Phone:401-568-7661
Mailing Address - Fax:401-567-0900
Practice Address - Street 1:36 BRIDGE WAY
Practice Address - Street 2:
Practice Address - City:PASCOAG
Practice Address - State:RI
Practice Address - Zip Code:02859-3131
Practice Address - Country:US
Practice Address - Phone:401-568-7661
Practice Address - Fax:401-567-0900
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTHWEST COMMUNITY HEALTH CARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-03-27
Last Update Date:2008-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIRAD0142261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI41-1814Medicare PIN