Basic Information
| Provider Information | |||||||||
| NPI: | 1558301077 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RIA ENDOVASCULAR, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10800 E GEDDES AVE STE 300 | ||||||||
| Address2: | |||||||||
| City: | ENGLEWOOD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801123895 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037619190 | ||||||||
| FaxNumber: | 7208744462 | ||||||||
| Practice Location | |||||||||
| Address1: | 8200 E BELLEVIEW AVE | ||||||||
| Address2: | #600E | ||||||||
| City: | GREENWOOD VILLAGE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 80111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7204933406 | ||||||||
| FaxNumber: | 3036434510 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2006 | ||||||||
| LastUpdateDate: | 12/24/2020 | ||||||||
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| AuthorizedOfficialLastName: | GRILLO | ||||||||
| AuthorizedOfficialFirstName: | GRACEANN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING SUPERVISOR | ||||||||
| AuthorizedOfficialTelephone: | 7204933716 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 12/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | DD7304 | 01 | RR MEDICARE IVLC | OTHER | 7655666 | 01 | AETNA IVLC | OTHER | 30058082 | 05 | CO | MEDICAID |