Basic Information
| Provider Information | |||||||||
| NPI: | 1407836935 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ATHALE | ||||||||
| FirstName: | SANJEEV | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3700 PARK EAST DR | ||||||||
| Address2: | SUITE 450 | ||||||||
| City: | BEACHWOOD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441224305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8552921401 | ||||||||
| FaxNumber: | 8663968340 | ||||||||
| Practice Location | |||||||||
| Address1: | 3700 PARK EAST DR | ||||||||
| Address2: | SUITE 450 | ||||||||
| City: | BEACHWOOD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441224305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8552921401 | ||||||||
| FaxNumber: | 8663968340 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/19/2006 | ||||||||
| LastUpdateDate: | 05/31/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085N0904X | A114198 | CA | N | Allopathic & Osteopathic Physicians | Radiology | Nuclear Radiology | 2085N0904X | 233479 | NY | Y | Allopathic & Osteopathic Physicians | Radiology | Nuclear Radiology |
ID Information
| ID | Type | State | Issuer | Description | 1407836935 | 05 | CA | MEDICAID |