Provider Demographics
NPI:1114438769
Name:ADVANCED MIDWEST INTERVENTIONAL RADIOLOGY, LLC
Entity type:Organization
Organization Name:ADVANCED MIDWEST INTERVENTIONAL RADIOLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:TARRA
Authorized Official - Middle Name:
Authorized Official - Last Name:GRANT
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:815-900-9060
Mailing Address - Street 1:3010 HIGHLAND PKWY STE 325
Mailing Address - Street 2:
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60515-5670
Mailing Address - Country:US
Mailing Address - Phone:630-581-6524
Mailing Address - Fax:
Practice Address - Street 1:1890 SILVER CROSS BLVD STE 450
Practice Address - Street 2:
Practice Address - City:NEW LENOX
Practice Address - State:IL
Practice Address - Zip Code:60451-9518
Practice Address - Country:US
Practice Address - Phone:815-900-9060
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-21
Last Update Date:2025-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Single Specialty