Basic Information
Provider Information | |||||||||
NPI: | 1427008937 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SUBURBAN IMAGING, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2355 HWY 36 W. | ||||||||
Address2: | STE. 100 | ||||||||
City: | ROSEVILLE | ||||||||
State: | MN | ||||||||
PostalCode: | 55113 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6512922000 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2355 HWY 36 W. | ||||||||
Address2: | STE. 100 | ||||||||
City: | ROSEVILLE | ||||||||
State: | MN | ||||||||
PostalCode: | 55113 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6512922000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/12/2006 | ||||||||
LastUpdateDate: | 06/30/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MADISON | ||||||||
AuthorizedOfficialFirstName: | MICHAEL | ||||||||
AuthorizedOfficialMiddleName: | T | ||||||||
AuthorizedOfficialTitleorPosition: | CEO, PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 6512922000 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
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 |