Basic Information
| Provider Information | |||||||||
| NPI: | 1467731885 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MEDIRAD, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12425 W BELL RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | SURPRISE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853789006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6233747774 | ||||||||
| FaxNumber: | 6232401110 | ||||||||
| Practice Location | |||||||||
| Address1: | 12425 W BELL RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | SURPRISE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853789006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6233747774 | ||||||||
| FaxNumber: | 6232401110 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2011 | ||||||||
| LastUpdateDate: | 09/11/2020 | ||||||||
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| AuthorizedOfficialLastName: | NGUYEN | ||||||||
| AuthorizedOfficialFirstName: | LINH | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | CMIO/CEO | ||||||||
| AuthorizedOfficialTelephone: | 6233747774 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | 09/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.