Basic Information
| Provider Information | |||||||||
| NPI: | 1871538223 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PROGRESSIVE RADIOLOGY, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10335 N PORT WASHINGTON RD | ||||||||
| Address2: | SUITE 250 | ||||||||
| City: | MEQUON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530925763 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2622409870 | ||||||||
| FaxNumber: | 2622409869 | ||||||||
| Practice Location | |||||||||
| Address1: | 308 WILLOW AVE | ||||||||
| Address2: | RADIOLOGY DEPARTMENT | ||||||||
| City: | HOBOKEN | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070303808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2014181820 | ||||||||
| FaxNumber: | 2014181822 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2006 | ||||||||
| LastUpdateDate: | 10/31/2007 | ||||||||
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| AuthorizedOfficialLastName: | BAHRAMIPOUR | ||||||||
| AuthorizedOfficialFirstName: | PHILLIP | ||||||||
| AuthorizedOfficialMiddleName: | FAROKH | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2014181820 | ||||||||
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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 | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 9058907 | 05 | NJ | MEDICAID |