Provider Demographics
NPI:1043470933
Name:VASCULAR AND INTERVENTIONAL RADIOLOGY CLINIC OF JACKSON
Entity type:Organization
Organization Name:VASCULAR AND INTERVENTIONAL RADIOLOGY CLINIC OF JACKSON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:T
Authorized Official - Last Name:GRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:731-541-6174
Mailing Address - Street 1:PO BOX 3614
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38303-3614
Mailing Address - Country:US
Mailing Address - Phone:731-541-8854
Mailing Address - Fax:
Practice Address - Street 1:300 COATSLAND DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38301-3908
Practice Address - Country:US
Practice Address - Phone:731-541-8854
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-13
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology