Basic Information
| Provider Information | |||||||||
| NPI: | 1356316954 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INTERVENTIONAL RADIOLOGY, LTD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 27340 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850617340 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6029439200 | ||||||||
| FaxNumber: | 6022163000 | ||||||||
| Practice Location | |||||||||
| Address1: | 1800 E VAN BUREN ST | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850063742 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022542123 | ||||||||
| FaxNumber: | 6022544172 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/17/2006 | ||||||||
| LastUpdateDate: | 12/05/2007 | ||||||||
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| AuthorizedOfficialLastName: | ESPLIN | ||||||||
| AuthorizedOfficialFirstName: | CORDELL | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6022542123 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0204X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology |
ID Information
| ID | Type | State | Issuer | Description | 874801 | 05 | AZ | MEDICAID | 1Z7077 | 01 | AZ | HEALTH NET OF AZ | OTHER |