Provider Demographics
NPI:1750788865
Name:NORTHSTAR RADIOLOGY - CALIFORNIA
Entity type:Organization
Organization Name:NORTHSTAR RADIOLOGY - CALIFORNIA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:LECKIE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:775-853-8422
Mailing Address - Street 1:2031 32ND ST S
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-7099
Mailing Address - Country:US
Mailing Address - Phone:608-788-8103
Mailing Address - Fax:608-788-8799
Practice Address - Street 1:1800 SPRING RIDGE DR
Practice Address - Street 2:
Practice Address - City:SUSANVILLE
Practice Address - State:CA
Practice Address - Zip Code:96130-6100
Practice Address - Country:US
Practice Address - Phone:608-788-8103
Practice Address - Fax:608-788-8799
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-04
Last Update Date:2015-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACA145272Medicare PIN
CACA145271Medicare PIN