Provider Demographics
NPI:1053615021
Name:ARIZONA INTERVENTIONAL MEDICAL GROUP PC
Entity type:Organization
Organization Name:ARIZONA INTERVENTIONAL MEDICAL GROUP PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:J
Authorized Official - Middle Name:THEODORE
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-725-2768
Mailing Address - Street 1:1901 BUTTERFIELD RD
Mailing Address - Street 2:220
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60515-7915
Mailing Address - Country:US
Mailing Address - Phone:630-725-2768
Mailing Address - Fax:877-219-4810
Practice Address - Street 1:2338 W ROYAL PALM RD
Practice Address - Street 2:SUITE J
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85021-9339
Practice Address - Country:US
Practice Address - Phone:630-725-2768
Practice Address - Fax:877-219-4810
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-05
Last Update Date:2011-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ426462085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Multi-Specialty