Basic Information
| Provider Information | |||||||||
| NPI: | 1679513196 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RADIOLOGY IMAGING ASSOCIATES, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10800 E GEDDES AVE | ||||||||
| Address2: | |||||||||
| City: | ENGLEWOOD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801123894 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037619190 | ||||||||
| FaxNumber: | 7208744462 | ||||||||
| Practice Location | |||||||||
| Address1: | 10800 E GEDDES AVE STE 300 | ||||||||
| Address2: | |||||||||
| City: | ENGLEWOOD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801123895 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037619190 | ||||||||
| FaxNumber: | 7208744462 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2006 | ||||||||
| LastUpdateDate: | 04/09/2021 | ||||||||
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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: | 04/09/2021 | ||||||||
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 | 074088802 | 05 | TX | MEDICAID | 1528962 | 05 | TN | MEDICAID | 1679513196 | 05 | MT | MEDICAID | G9020 | 05 | NM | MEDICAID | 107475000 | 05 | WY | MEDICAID | 4220042 | 05 | CO | MEDICAID | 0560060 | 05 | IA | MEDICAID | CO1609 | 01 | HEALTHNET NE RIA | OTHER | 100370940B | 05 | KS | MEDICAID | 201053620 | 01 | PRES SALUD MEDICAID | OTHER | MPG0457 | 05 | AK | MEDICAID | RA22004 | 01 | BCBS RIA | OTHER | 1679513196 | 05 | ID | MEDICAID | 695538 | 05 | AZ | MEDICAID | 000901750 0003 | 05 | PA | MEDICAID | CD2044 | 01 | RR MEDICARE RIA | OTHER | 100006790A | 05 | IN | MEDICAID | 196643002 | 05 | AR | MEDICAID | 8161045 | 01 | AETNA RIA | OTHER | QPB657 | 05 | SC | MEDICAID |