Basic Information
| Provider Information | |||||||||
| NPI: | 1255481313 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INTERVENTIONAL RADIOLOGY SERVICES, LP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1130 TEN ROD RD | ||||||||
| Address2: | D201 | ||||||||
| City: | NORTH KINGSTOWN | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028524161 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8775917250 | ||||||||
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| Practice Location | |||||||||
| Address1: | 9600 GROSS POINT RD | ||||||||
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| City: | SKOKIE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600761214 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8479336100 | ||||||||
| FaxNumber: | 8479336110 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/11/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | EDELMAN | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 8775917250 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0204X | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology |
No ID Information.