1013046366 NPI number — SALEM FLORA RADIOLOGY, S.C.

Table of content: (NPI 1013046366)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013046366 NPI number — SALEM FLORA RADIOLOGY, S.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SALEM FLORA RADIOLOGY, S.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1013046366
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/20/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
815 W MAIN ST
Provider Second Line Business Mailing Address:
P.O. BOX 875
Provider Business Mailing Address City Name:
SALEM
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62881-1408
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-548-2843
Provider Business Mailing Address Fax Number:
618-548-2896

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
815 W MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SALEM
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62881-1408
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-548-2843
Provider Business Practice Location Address Fax Number:
618-548-2896
Provider Enumeration Date:
03/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
TAWJAREON
Authorized Official First Name:
PREECHA
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER, PRESIDENT
Authorized Official Telephone Number:
618-548-2843

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0202X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: CF1003 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: P04756 . This is a "FLORA PIN #" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 0006115210 . This is a "BLUECROSS BLUESHIELD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: L06343 . This is a "SALEM PIN #" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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