Healthcare Provider Details

I. General information

NPI: 1235204322
Provider Name (Legal Business Name): IMAGING CENTER OF SALEM, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/22/2006
Last Update Date: 01/26/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1325D W WHITTAKER ST
SALEM IL
62881
US

IV. Provider business mailing address

PO BOX 31249
SAINT LOUIS MO
63131-0249
US

V. Phone/Fax

Practice location:
  • Phone: 618-548-3796
  • Fax: 618-548-3050
Mailing address:
  • Phone: 314-966-6070
  • Fax: 314-966-3440

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RM1200X
TaxonomyMagnetic Resonance Imaging (MRI) Internal Medicine Physician
License Number
License Number StateIL

VIII. Authorized Official

Name: MRS. LU ANN BOGOLIN
Title or Position: BILLING MNGR
Credential:
Phone: 314-966-6070