Healthcare Provider Details

I. General information

NPI: 1730218652
Provider Name (Legal Business Name): RADIOLOGIC INTERPRETATIONS OF SOUTHERN ILLINOIS LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/05/2007
Last Update Date: 11/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 CEDAR COURT
CARBONDALE IL
62901-5334
US

IV. Provider business mailing address

1200 CEDAR COURT
CARBONDALE IL
62901-5334
US

V. Phone/Fax

Practice location:
  • Phone: 618-529-8500
  • Fax: 618-549-1000
Mailing address:
  • Phone: 618-529-8500
  • Fax: 618-549-1000

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247100000X
TaxonomyRadiologic Technologist
License Number
License Number State

VIII. Authorized Official

Name: DR. DOUGLAS L FULK
Title or Position: PRESIDENT
Credential: MD
Phone: 618-529-8500