Provider Demographics
NPI:1184305526
Name:IRVING RADIOLOGY, INC
Entity type:Organization
Organization Name:IRVING RADIOLOGY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WINSTON
Authorized Official - Middle Name:DACOSTA
Authorized Official - Last Name:IRVING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-935-0770
Mailing Address - Street 1:4011 S MONROE MEDICAL PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403
Mailing Address - Country:US
Mailing Address - Phone:239-309-0602
Mailing Address - Fax:
Practice Address - Street 1:4011 S MONROE MEDICAL PARK BLVD
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403
Practice Address - Country:US
Practice Address - Phone:239-309-0602
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:IRVING RADIOLOGY, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-07-28
Last Update Date:2023-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN99119700AMedicaid