Basic Information
| Provider Information | |||||||||
| NPI: | 1427008937 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SUBURBAN IMAGING, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2355 HWY 36 W. | ||||||||
| Address2: | STE. 100 | ||||||||
| City: | ROSEVILLE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512922000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2355 HWY 36 W. | ||||||||
| Address2: | STE. 100 | ||||||||
| City: | ROSEVILLE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512922000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2006 | ||||||||
| LastUpdateDate: | 06/30/2020 | ||||||||
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| AuthorizedOfficialLastName: | MADISON | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO, PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6512922000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 06/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0200X | 261 | MN | Y | Ambulatory Health Care Facilities | Clinic/Center | Radiology |
ID Information
| ID | Type | State | Issuer | Description | 8496889-00 | 05 | MN | MEDICAID | DA3809 | 01 | RAILROAD MEDICARE | OTHER |