Basic Information
Provider Information | |||||||||
NPI: | 1053615021 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ARIZONA INTERVENTIONAL MEDICAL GROUP PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
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Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
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OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1901 BUTTERFIELD RD | ||||||||
Address2: | 220 | ||||||||
City: | DOWNERS GROVE | ||||||||
State: | IL | ||||||||
PostalCode: | 605157915 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6307252768 | ||||||||
FaxNumber: | 8772194810 | ||||||||
Practice Location | |||||||||
Address1: | 2338 W ROYAL PALM RD | ||||||||
Address2: | SUITE J | ||||||||
City: | PHOENIX | ||||||||
State: | AZ | ||||||||
PostalCode: | 850219339 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6307252768 | ||||||||
FaxNumber: | 8772194810 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/05/2011 | ||||||||
LastUpdateDate: | 01/05/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | KING | ||||||||
AuthorizedOfficialFirstName: | J | ||||||||
AuthorizedOfficialMiddleName: | THEODORE | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 6307252768 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
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NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0204X | 42646 | AZ | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology |
No ID Information.