Basic Information
| Provider Information | |||||||||
| NPI: | 1780016394 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CLINICAL RADIOLOGISTS, S.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3050 MONTVALE DR | ||||||||
| Address2: | SUITE A | ||||||||
| City: | SPRINGFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 627044290 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2177263389 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1005 BROADWAY ST | ||||||||
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| City: | QUINCY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 623012834 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2172231200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/06/2013 | ||||||||
| LastUpdateDate: | 08/06/2013 | ||||||||
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| AuthorizedOfficialLastName: | DICKERSON | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2172229302 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CEO | ||||||||
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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.