Basic Information
| Provider Information | |||||||||
| NPI: | 1285790519 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THE CARBONDALE CLINIC RADIOLOGY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2601 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | CARBONDALE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 629011031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184575200 | ||||||||
| FaxNumber: | 6185495128 | ||||||||
| Practice Location | |||||||||
| Address1: | 2601 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | CARBONDALE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 629011031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184575200 | ||||||||
| FaxNumber: | 6185495128 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/29/2006 | ||||||||
| LastUpdateDate: | 05/08/2008 | ||||||||
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| AuthorizedOfficialLastName: | NORMAN | ||||||||
| AuthorizedOfficialFirstName: | ALLAN | ||||||||
| AuthorizedOfficialMiddleName: | N | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6184575200 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | THE CARBONDALE CLINIC, S.C. | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 614350 | 01 | IL | LEGACY | OTHER | 044651 | 01 | IL | HAMP | OTHER | 464790 | 01 | IL | HEALTHLINK | OTHER | 690006448 | 01 | IL | RR MEDICARE | OTHER | 196090 | 01 | IL | GHP | OTHER |