Provider Demographics
NPI:1932803145
Name:RADRAD GROUP OF IL SC
Entity type:Organization
Organization Name:RADRAD GROUP OF IL SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER/AUTHORIZED REP
Authorized Official - Prefix:DR
Authorized Official - First Name:TENNYSON
Authorized Official - Middle Name:
Authorized Official - Last Name:MALIRO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-503-9055
Mailing Address - Street 1:PO BOX 7065
Mailing Address - Street 2:
Mailing Address - City:LOVELAND
Mailing Address - State:CO
Mailing Address - Zip Code:80537-0065
Mailing Address - Country:US
Mailing Address - Phone:970-663-2742
Mailing Address - Fax:970-667-0847
Practice Address - Street 1:500 N MCLEAN BLVD # 103
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123-3275
Practice Address - Country:US
Practice Address - Phone:224-227-6178
Practice Address - Fax:224-227-6178
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-30
Last Update Date:2023-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty