Healthcare Provider Details

I. General information

NPI: 1891782090
Provider Name (Legal Business Name): LAKELAND RADIOLOGISTS LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2005
Last Update Date: 02/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

907 W LINCOLN AVE
CHARLESTON IL
61920-2413
US

IV. Provider business mailing address

907 W LINCOLN AVE PO BOX 770
CHARLESTON IL
61920-2413
US

V. Phone/Fax

Practice location:
  • Phone: 312-574-0076
  • Fax: 888-453-0505
Mailing address:
  • Phone: 217-235-7701
  • Fax: 217-345-8366

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: ALDO C RUFFOLO
Title or Position: PRESIDENT
Credential: DO
Phone: 217-345-2100