Healthcare Provider Details

I. General information

NPI: 1467417931
Provider Name (Legal Business Name): INMED DIAGNOSTIC SERVICES OF IL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2006
Last Update Date: 12/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4119 S WATER TOWER PLACE SUITE A
MT. VERNON IL
62864-9595
US

IV. Provider business mailing address

2400 E. COMMERCIAL SUITE 826
FT. LAUDERDALE FL
33308
US

V. Phone/Fax

Practice location:
  • Phone: 618-985-8007
  • Fax: 618-985-8031
Mailing address:
  • Phone: 954-510-3700
  • Fax: 954-510-2649

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: ELIZABETH LONGTON
Title or Position: COO
Credential:
Phone: 954-510-3704