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General NPI Number Information
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NPI Number | 1114438769
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Entity Type | Organization
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Legal Business Name | ADVANCED MIDWEST INTERVENTIONAL RADIOLOGY, LLC
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Dates
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Enumeration Date | 10/21/2017
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Last Update Date | 03/07/2025
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Provider Practice Location Address
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Address Line | 1890 SILVER CROSS BLVD STE 450
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City | NEW LENOX
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State | IL
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Zip | 60451-9518
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Country | US
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Telephone | 815-900-9060
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Fax |
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Provider Business Mailing Address
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Address Line | 3010 HIGHLAND PKWY STE 325
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City | DOWNERS GROVE
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State | IL
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Zip | 60515-5670
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Country | US
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Telephone | 630-581-6524
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Fax |
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Authorized Official
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Title or Position | PRACTICE MANAGER
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Name | MS. TARRA GRANT
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Credential | MA
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Telephone | 815-900-9060
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2085R0204X
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Taxonomy Name | Vascular & Interventional Radiology Physician
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License Number |
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License Number State |
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