Provider Demographics
NPI:1215260955
Name:WILLISTON RADIOLOGY CONSULTANTS PC
Entity type:Organization
Organization Name:WILLISTON RADIOLOGY CONSULTANTS PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:LESZEK
Authorized Official - Middle Name:
Authorized Official - Last Name:JASZCZAK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:701-577-6337
Mailing Address - Street 1:3 4TH ST E
Mailing Address - Street 2:SUITE 201
Mailing Address - City:WILLISTON
Mailing Address - State:ND
Mailing Address - Zip Code:58801-5350
Mailing Address - Country:US
Mailing Address - Phone:701-577-6337
Mailing Address - Fax:701-577-4867
Practice Address - Street 1:3 4TH ST E
Practice Address - Street 2:SUITE 201
Practice Address - City:WILLISTON
Practice Address - State:ND
Practice Address - Zip Code:58801-5350
Practice Address - Country:US
Practice Address - Phone:701-577-6337
Practice Address - Fax:701-577-4867
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-14
Last Update Date:2020-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND261QU0200X261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND261QU0200XOtherTAXONOMY
ND010182Medicaid
MT0406731Medicaid
ND621111OtherNAICS
ND109956169OtherDUNS
ND2699617243OtherTPIN
NDN6228Medicare UPIN