Basic Information
Provider Information | |||||||||
NPI: | 1518283597 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | EDWARD HOSPITAL IMAGING CENTER PLAINFIELD | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 801 S WASHINGTON ST | ||||||||
Address2: |   | ||||||||
City: | NAPERVILLE | ||||||||
State: | IL | ||||||||
PostalCode: | 605407430 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6305273000 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 24600 W 127TH ST | ||||||||
Address2: |   | ||||||||
City: | PLAINFIELD | ||||||||
State: | IL | ||||||||
PostalCode: | 605859507 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8157313000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/15/2010 | ||||||||
LastUpdateDate: | 04/16/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | DAVIS | ||||||||
AuthorizedOfficialFirstName: | PAM | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PESIDENT AND CEO | ||||||||
AuthorizedOfficialTelephone: | 6305273010 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0200X |   | IL | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Radiology |
No ID Information.