Healthcare Provider Details

I. General information

NPI: 1740406107
Provider Name (Legal Business Name): SUBURBAN DIAGNOSTIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2007
Last Update Date: 05/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11600 LEGACY DR
PLAINFIELD IL
60585-5194
US

IV. Provider business mailing address

11600 LEGACY DR
PLAINFIELD IL
60585-5194
US

V. Phone/Fax

Practice location:
  • Phone: 815-577-8200
  • Fax: 815-577-8300
Mailing address:
  • Phone: 815-577-8200
  • Fax: 815-577-8300

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335V00000X
TaxonomyPortable X-ray and/or Other Portable Diagnostic Imaging Supplier
License Number500483643
License Number StateIL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier364369726001
Identifier TypeMEDICAID
Identifier StateIL
Identifier Issuer
# 2
Identifier09932186
Identifier TypeOTHER
Identifier StateIL
Identifier IssuerBCBS

VIII. Authorized Official

Name: GLENN PADILLA
Title or Position: OWNER
Credential: RT
Phone: 815-577-8200