Basic Information
| Provider Information | |||||||||
| NPI: | 1598741324 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MONTVALE IMAGING PHYSICIANS PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9137 | ||||||||
| Address2: | |||||||||
| City: | BROOKLINE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 024469137 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8009270002 | ||||||||
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| Practice Location | |||||||||
| Address1: | 48 MONTVALE AVE | ||||||||
| Address2: | |||||||||
| City: | STONEHAM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021802425 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7812792213 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/22/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | O'REILLY | ||||||||
| AuthorizedOfficialFirstName: | GERARD | ||||||||
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| AuthorizedOfficialTitleorPosition: | MD | ||||||||
| AuthorizedOfficialTelephone: | 8009270002 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | MA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 9785361 | 05 | MA | MEDICAID |