Basic Information
| Provider Information | |||||||||
| NPI: | 1316056021 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DES PLAINES RADIOLOGISTS SC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6910 S MADISON | ||||||||
| Address2: | |||||||||
| City: | WILLOWBROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60527 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6306546509 | ||||||||
| FaxNumber: | 6303231699 | ||||||||
| Practice Location | |||||||||
| Address1: | 1455 GOLF RD | ||||||||
| Address2: | SUITE 212 | ||||||||
| City: | DES PLAINES | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8472971800 | ||||||||
| FaxNumber: | 6303231699 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | BITNER | ||||||||
| AuthorizedOfficialFirstName: | PATRICIA | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6306546503 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | CPC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | CN0576 | 01 | RR MEDICARE | OTHER | GR1615479 | 01 | BCBS | OTHER |