Provider Demographics
NPI:1043478159
Name:VOYAGEUR RADIOLOGY LLC
Entity type:Organization
Organization Name:VOYAGEUR RADIOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:D
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:651-492-5877
Mailing Address - Street 1:9975 DELLWOOD RD N
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:MN
Mailing Address - Zip Code:55082-9425
Mailing Address - Country:US
Mailing Address - Phone:651-429-7026
Mailing Address - Fax:
Practice Address - Street 1:9975 DELLWOOD RD N
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:MN
Practice Address - Zip Code:55082-9425
Practice Address - Country:US
Practice Address - Phone:651-429-7026
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-26
Last Update Date:2011-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN285242085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI000049019Medicare PIN
IAIB2046006Medicare PIN
MNC05170Medicare PIN
MT011003806Medicare PIN