Basic Information
| Provider Information | |||||||||
| NPI: | 1881614667 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VOSSOUGH MODARRESS | ||||||||
| FirstName: | ARASTOO | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | VOSSOUGH | ||||||||
| OtherFirstName: | ARASTOO | ||||||||
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| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 100 E PENN SQ | ||||||||
| Address2: | 9TH FLOOR | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191073323 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2674259232 | ||||||||
| FaxNumber: | 2674259299 | ||||||||
| Practice Location | |||||||||
| Address1: | 3401 CIVIC CENTER BLVD | ||||||||
| Address2: | CHILDREN'S HOSPITAL OF PHILADELPHIA - RADIOLOGY | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191044319 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2155901030 | ||||||||
| FaxNumber: | 2155909348 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2006 | ||||||||
| LastUpdateDate: | 05/15/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085N0700X | 220265 | MA | N | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology | 2085N0700X | MD430990 | PA | Y | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology | 2085R0202X | 220265 | MA | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | MD430990 | PA | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 25MA09281700 | NJ | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085N0700X | 25MA09281700 | NJ | N | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology |
ID Information
| ID | Type | State | Issuer | Description | 2068915 | 05 | MA | MEDICAID |