Basic Information
| Provider Information | |||||||||
| NPI: | 1417305350 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PALOS IMAGING, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12251 S. 80TH AVENUE | ||||||||
| Address2: | SUITE 1630 | ||||||||
| City: | PALOS HEIGHTS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60463 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7089235173 | ||||||||
| FaxNumber: | 7089235018 | ||||||||
| Practice Location | |||||||||
| Address1: | 15300 WEST AVENUE | ||||||||
| Address2: | |||||||||
| City: | ORLAND PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60462 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7082262500 | ||||||||
| FaxNumber: | 7082262509 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2016 | ||||||||
| LastUpdateDate: | 03/06/2017 | ||||||||
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| AuthorizedOfficialLastName: | MOISAN | ||||||||
| AuthorizedOfficialFirstName: | TERRENCE | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7089235000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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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 |
No ID Information.