Basic Information
| Provider Information | |||||||||
| NPI: | 1578605994 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | IMAGING CENTER OF ALTON, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 132 N KANSAS ST STE 212 | ||||||||
| Address2: | P.O. BOX 868 | ||||||||
| City: | EDWARDSVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620251782 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6186552400 | ||||||||
| FaxNumber: | 6186591197 | ||||||||
| Practice Location | |||||||||
| Address1: | 3 PROFESSIONAL DR | ||||||||
| Address2: | SUITE A | ||||||||
| City: | ALTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620025067 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184654674 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | MCRAE | ||||||||
| AuthorizedOfficialFirstName: | STEVEN | ||||||||
| AuthorizedOfficialMiddleName: | M. | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6186552400 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Radiology |
No ID Information.