Provider Demographics
NPI:1780638494
Name:ADVANCED RADIOLOGY, INC.
Entity Type:Organization
Organization Name:ADVANCED RADIOLOGY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:S
Authorized Official - Last Name:TKACH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:401-725-6736
Mailing Address - Street 1:525 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND
Mailing Address - State:RI
Mailing Address - Zip Code:02864-6919
Mailing Address - Country:US
Mailing Address - Phone:401-727-4600
Mailing Address - Fax:401-727-4690
Practice Address - Street 1:525 BROAD ST
Practice Address - Street 2:
Practice Address - City:CUMBERLAND
Practice Address - State:RI
Practice Address - Zip Code:02864-6919
Practice Address - Country:US
Practice Address - Phone:401-727-4600
Practice Address - Fax:401-727-4690
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI7006349Medicaid