Provider Demographics
NPI:1306881800
Name:ADVANCED RADIOLOGY OF GRAND ISLAND, PC
Entity type:Organization
Organization Name:ADVANCED RADIOLOGY OF GRAND ISLAND, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:L
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:308-398-1344
Mailing Address - Street 1:730 N DIERS AVE
Mailing Address - Street 2:
Mailing Address - City:GRAND ISLAND
Mailing Address - State:NE
Mailing Address - Zip Code:68803-4954
Mailing Address - Country:US
Mailing Address - Phone:308-398-1344
Mailing Address - Fax:308-398-1346
Practice Address - Street 1:730 N DIERS AVE
Practice Address - Street 2:
Practice Address - City:GRAND ISLAND
Practice Address - State:NE
Practice Address - Zip Code:68803-4954
Practice Address - Country:US
Practice Address - Phone:308-398-1344
Practice Address - Fax:308-398-1346
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-18
Last Update Date:2016-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NEDE0658OtherRAILROAD MEDICARE
NE10025333200Medicaid
NE10025333200Medicaid