Basic Information
| Provider Information | |||||||||
| NPI: | 1154798882 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ALTON MULTISPECIALISTS, LTD. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ALTON MULTISPECIALISTS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 PROFESSIONAL DR | ||||||||
| Address2: | |||||||||
| City: | ALTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620025068 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184638500 | ||||||||
| FaxNumber: | 6184740130 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 PROFESSIONAL DR | ||||||||
| Address2: | |||||||||
| City: | ALTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620025068 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184638500 | ||||||||
| FaxNumber: | 6184740130 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2015 | ||||||||
| LastUpdateDate: | 08/28/2015 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HENSON | ||||||||
| AuthorizedOfficialFirstName: | SHERRI | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6184638534 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ALTON MULTISPECIALISTS, LTD. | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0206X | Y | Ambulatory Health Care Facilities | Clinic/Center | Radiology, Mammography |
ID Information
| ID | Type | State | Issuer | Description | 100867 | 01 | IL | MAMMOGRAPHY SERVICES | OTHER |