Provider Demographics
NPI:1316965064
Name:HEALTHEAST MEDICAL IMAGING LLC
Entity type:Organization
Organization Name:HEALTHEAST MEDICAL IMAGING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:DOUG
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVENPORT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-232-2250
Mailing Address - Street 1:3640 TALMAGE CIRCLE
Mailing Address - Street 2:STE 100
Mailing Address - City:VADNAIS HEIGHTS
Mailing Address - State:MN
Mailing Address - Zip Code:55110
Mailing Address - Country:US
Mailing Address - Phone:651-426-7226
Mailing Address - Fax:651-426-7235
Practice Address - Street 1:3640 TALMAGE CIRCLE
Practice Address - Street 2:STE 100
Practice Address - City:VADNAIS HEIGHTS
Practice Address - State:MN
Practice Address - Zip Code:55110
Practice Address - Country:US
Practice Address - Phone:651-426-7226
Practice Address - Fax:651-426-7235
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-18
Last Update Date:2015-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN161668400Medicaid
MN470000050Medicare PIN