Organization
PHOENIX RADIOLOGY, PLLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. MARK W PETERSON M.D. (OWNER)
(208) 743-4393
Entity
Organization
Contact information
Practice address
415 6TH ST, LEWISTON, ID 83501-2431
(208) 799-5335
Mailing address
531 4TH AVE, LEWISTON, ID 83501-2450
(208) 743-4393
(208) 743-4214
Taxonomy
Speciality
Code
Description
License number
State
2085R0202X
Diagnostic Radiology Physician
—
—
2085R0204X
Vascular & Interventional Radiology Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000010148406
REGENCE BS OF IDAHO
ID
01
—
0192979
LABOR & INDUSTRIES
WA
05
—
7124605
—
WA
01
—
8J679
BLUE CROSS OF IDAHO
ID
01
—
DC3860
RAILROAD MEDICARE
—
Enumeration date
01/27/2006
Last updated
09/11/2025
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