Healthcare Provider Details

I. General information

NPI: 1730652017
Provider Name (Legal Business Name): DIASPORA RADIOLOGY, SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2019
Last Update Date: 07/08/2024
Certification Date: 07/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2602 MULBERRY LN
NORTHBROOK IL
60062-5937
US

IV. Provider business mailing address

2602 MULBERRY LN
NORTHBROOK IL
60062-5937
US

V. Phone/Fax

Practice location:
  • Phone: 855-694-3300
  • Fax:
Mailing address:
  • Phone: 314-238-5260
  • Fax: 314-821-1833

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1200X
TaxonomyMagnetic Resonance Imaging (MRI) Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: MARIA CORONA
Title or Position: SENIOR DIRECTOR OPERATIONS
Credential:
Phone: 855-694-3300