Basic Information
| Provider Information | |||||||||
| NPI: | 1346228848 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TRI COUNTY RADIOLOGY | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3853 | ||||||||
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| City: | PEORIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 616123853 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8008995757 | ||||||||
| FaxNumber: | 3148211833 | ||||||||
| Practice Location | |||||||||
| Address1: | 5409 N KNOXVILLE AVE | ||||||||
| Address2: | |||||||||
| City: | PEORIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 61615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3096827750 | ||||||||
| FaxNumber: | 3096827786 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | COOPER | ||||||||
| AuthorizedOfficialFirstName: | W | ||||||||
| AuthorizedOfficialMiddleName: | ROBERT | ||||||||
| AuthorizedOfficialTitleorPosition: | CMPE, CHBC | ||||||||
| AuthorizedOfficialTelephone: | 3096827750 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085N0904X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Nuclear Radiology | 2085B0100X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Body Imaging | 2085U0001X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Ultrasound | 2085R0204X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology |
ID Information
| ID | Type | State | Issuer | Description | 0007222342 | 01 | IL | BLUE CROSS BLUE SHIELD | OTHER | IL0100 | 01 | IL | JOHN DEERE | OTHER |