Basic Information
| Provider Information | |||||||||
| NPI: | 1396737268 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INTERVENTIONAL ASSOCIATES OF MEMPHIS, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 66 N PAULINE ST | ||||||||
| Address2: | SUITE 206 | ||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381055105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9014482786 | ||||||||
| FaxNumber: | 9014481772 | ||||||||
| Practice Location | |||||||||
| Address1: | 66 N PAULINE ST | ||||||||
| Address2: | SUITE 206 | ||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381055105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9014482786 | ||||||||
| FaxNumber: | 9014481772 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2005 | ||||||||
| LastUpdateDate: | 05/27/2008 | ||||||||
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| AuthorizedOfficialLastName: | WOODSIDE | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
| AuthorizedOfficialMiddleName: | R. | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF MEDICAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 9014481644 | ||||||||
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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 | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology |
No ID Information.