Basic Information
| Provider Information | |||||||||
| NPI: | 1518077197 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PROFESSIONAL IMAGING CONSULTANTS, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 W MAIN ST | ||||||||
| Address2: | SUITE 108 | ||||||||
| City: | BABYLON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117023027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6319305215 | ||||||||
| FaxNumber: | 6315178007 | ||||||||
| Practice Location | |||||||||
| Address1: | 3614 VICTORIA AVE | ||||||||
| Address2: | |||||||||
| City: | MOUNT VERNON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 628642208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6183156058 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2006 | ||||||||
| LastUpdateDate: | 03/15/2013 | ||||||||
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| AuthorizedOfficialLastName: | ST. JOHN | ||||||||
| AuthorizedOfficialFirstName: | JACKIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CONTRACTING & CREDENTIALING | ||||||||
| AuthorizedOfficialTelephone: | 6319305215 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.