Healthcare Provider Details

I. General information

NPI: 1104378942
Provider Name (Legal Business Name): RADIOLOGY SUBSPECIALISTS OF NORTHERN ILLINOIS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/27/2016
Last Update Date: 10/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

825 W STATE ST SUITE 103E
GENEVA IL
60134-2080
US

IV. Provider business mailing address

825 W STATE ST SUITE 103E
GENEVA IL
60134-2080
US

V. Phone/Fax

Practice location:
  • Phone: 630-208-4412
  • Fax:
Mailing address:
  • Phone: 630-208-4412
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: DIANE SARKA
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 630-928-5234