Provider Demographics
NPI:1871538223
Name:PROGRESSIVE RADIOLOGY, LLC
Entity type:Organization
Organization Name:PROGRESSIVE RADIOLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:FAROKH
Authorized Official - Last Name:BAHRAMIPOUR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-418-1820
Mailing Address - Street 1:10335 N PORT WASHINGTON RD
Mailing Address - Street 2:SUITE 250
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-5763
Mailing Address - Country:US
Mailing Address - Phone:262-240-9870
Mailing Address - Fax:262-240-9869
Practice Address - Street 1:308 WILLOW AVE
Practice Address - Street 2:RADIOLOGY DEPARTMENT
Practice Address - City:HOBOKEN
Practice Address - State:NJ
Practice Address - Zip Code:07030-3808
Practice Address - Country:US
Practice Address - Phone:201-418-1820
Practice Address - Fax:201-418-1822
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-19
Last Update Date:2007-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ9058907Medicaid
NJ065726Medicare PIN