Healthcare Provider Details

I. General information

NPI: 1245287143
Provider Name (Legal Business Name): FT. JESSE IMAGING CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2006
Last Update Date: 10/21/2024
Certification Date: 10/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 FORT JESSE RD SUITE 130
NORMAL IL
61761-6286
US

IV. Provider business mailing address

2200 FORT JESSE RD SUITE 130
NORMAL IL
61761-6286
US

V. Phone/Fax

Practice location:
  • Phone: 309-454-5552
  • Fax: 309-454-5452
Mailing address:
  • Phone: 309-454-5552
  • Fax: 309-454-5452

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number9256804
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code261QR0206X
TaxonomyMammography Clinic/Center
License Number9256804
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: AMY STOUT
Title or Position: PRESIDENT/CEO
Credential:
Phone: 615-261-2306