Basic Information
Provider Information | |||||||||
NPI: | 1245490903 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CDI GENEVA LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | RAYUS RADIOLOGY | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5775 WAYZATA BLVD | ||||||||
Address2: | SUITE 400 | ||||||||
City: | ST LOUIS PARK | ||||||||
State: | MN | ||||||||
PostalCode: | 554161222 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9525256338 | ||||||||
FaxNumber: | 9525136880 | ||||||||
Practice Location | |||||||||
Address1: | 1416 S RANDALL RD | ||||||||
Address2: | SUITE C1 | ||||||||
City: | GENEVA | ||||||||
State: | IL | ||||||||
PostalCode: | 601344682 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6302089325 | ||||||||
FaxNumber: | 6302089326 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/16/2008 | ||||||||
LastUpdateDate: | 10/08/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | AHERN | ||||||||
AuthorizedOfficialFirstName: | RAMONA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | SPECIAL ASSISTANT SECRETARY | ||||||||
AuthorizedOfficialTelephone: | 9527384441 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/08/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.