Provider Demographics
NPI:1811992670
Name:VANCOUVER RADIOLOGISTS A PROFESSIONAL CORP
Entity type:Organization
Organization Name:VANCOUVER RADIOLOGISTS A PROFESSIONAL CORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT / CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:W R
Authorized Official - Last Name:SCHROEDER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:360-254-4914
Mailing Address - Street 1:4201 N.E. 66TH AVE.
Mailing Address - Street 2:SUITE 104
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98661
Mailing Address - Country:US
Mailing Address - Phone:360-254-4914
Mailing Address - Fax:
Practice Address - Street 1:4816 N.E. THURSTON WAY
Practice Address - Street 2:SUITE A
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98662
Practice Address - Country:US
Practice Address - Phone:360-254-4914
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-17
Last Update Date:2013-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2085R0202X
WA2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7833502Medicaid
682400Medicare ID - Type Unspecified