Healthcare Provider Details

I. General information

NPI: 1831865880
Provider Name (Legal Business Name): RADIOLOGY PARTNERS MANAGEMENT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/19/2021
Last Update Date: 09/21/2022
Certification Date: 09/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2330 UTAH AVE STE 200
EL SEGUNDO CA
90245-4817
US

IV. Provider business mailing address

PO BOX 686
WAUSAU WI
54402-0686
US

V. Phone/Fax

Practice location:
  • Phone: 312-724-8477
  • Fax:
Mailing address:
  • Phone: 404-480-2491
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: NAOMI M CASSIN
Title or Position: AVP, PROVIDER ENROLLMENT
Credential:
Phone: 312-724-8477