MEDICARE: ARIZONA INTERVENTIONAL MEDICAL GROUP PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2085R0204X	Vascular & Interventional Radiology Physician	42646	AZ

General Provider Information

NPI Number	:	1053615021
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ARIZONA INTERVENTIONAL MEDICAL GROUP PC

Provider Business Mailing Address
First Line	:	1901 BUTTERFIELD RD
Second Line	:	220
City	:	DOWNERS GROVE
State	:	IL
Zip	:	60515-7915
Country	:	US
Telephone Number	:	630-725-2768
Fax Number	:	877-219-4810

Provider Business Practice Location Address
First Line	:	2338 W ROYAL PALM RD
Second Line	:	SUITE J
City	:	PHOENIX
State	:	AZ
Zip	:	85021-9339
Country	:	US
Telephone Number	:	630-725-2768
Fax Number	:	877-219-4810

Authorized Official
Title or Position	:	OWNER
Name	:	J THEODORE KING
Credential	:
Telephone Number	:	630-725-2768

Provider Enumeration Date	:	01/05/2011
Last Update Date	:	01/05/2011

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