1548282114 NPI number — CHICAGO RIDGE RADIOLOGY SC

Table of content: (NPI 1548282114)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548282114 NPI number — CHICAGO RIDGE RADIOLOGY SC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHICAGO RIDGE RADIOLOGY SC
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:
1548282114
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/01/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2448 S 102ND ST
Provider Second Line Business Mailing Address:
STE 125
Provider Business Mailing Address City Name:
WEST ALLIS
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53227-2466
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-328-3800
Provider Business Mailing Address Fax Number:
414-328-3818

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9830 RIDGELAND AVE
Provider Second Line Business Practice Location Address:
STE #4
Provider Business Practice Location Address City Name:
CHICAGO RIDGE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60415-2667
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-423-1819
Provider Business Practice Location Address Fax Number:
708-423-4788
Provider Enumeration Date:
07/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
AMINE
Authorized Official First Name:
ABDUL
Authorized Official Middle Name:
Authorized Official Title or Position:
VICE PRESIDENT
Authorized Official Telephone Number:
708-430-3350

Provider Taxonomy Codes

  • Taxonomy code: 261QM1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 36043669 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com