Healthcare Provider Details

I. General information

NPI: 1578605994
Provider Name (Legal Business Name): IMAGING CENTER OF ALTON, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 PROFESSIONAL DR SUITE A
ALTON IL
62002-5067
US

IV. Provider business mailing address

132 N KANSAS ST STE 212 P.O. BOX 868
EDWARDSVILLE IL
62025-1782
US

V. Phone/Fax

Practice location:
  • Phone: 618-465-4674
  • Fax:
Mailing address:
  • Phone: 618-655-2400
  • Fax: 618-659-1197

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. STEVEN M. MCRAE
Title or Position: MANAGER
Credential:
Phone: 618-655-2400