Basic Information
| Provider Information | |||||||||
| NPI: | 1760443741 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEVY | ||||||||
| FirstName: | RONALD | ||||||||
| MiddleName: | P | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 36 GARDEN CTR | ||||||||
| Address2: | |||||||||
| City: | BROOMFIELD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800201730 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034650401 | ||||||||
| FaxNumber: | 3034042317 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 SAINT ANTHONYS WAY | ||||||||
| Address2: | |||||||||
| City: | ALTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620024568 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184654520 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2006 | ||||||||
| LastUpdateDate: | 02/07/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 036110681 | IL | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 34427 | MO | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | IL4399001 | 01 | IL | MEDICARE | OTHER | 036110681-2 | 01 | IL | MEDICAID | OTHER | 036110681-1 | 05 | IL | MEDICAID | P00142206 | 01 | IL | RAILROAD MEDICARE | OTHER |