Healthcare Provider Details

I. General information

NPI: 1629027594
Provider Name (Legal Business Name): SUBURBAN RADIOLOGIC CONSULTANTS, LTD.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2006
Last Update Date: 06/30/2020
Certification Date: 06/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2355 HWY 36 W. STE. 100
ROSEVILLE MN
55113-5511
US

IV. Provider business mailing address

2355 HWY 36 W. STE. 100
ROSEVILLE MN
55113
US

V. Phone/Fax

Practice location:
  • Phone: 651-292-2000
  • Fax:
Mailing address:
  • Phone: 651-292-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number261
License Number StateMN

VIII. Authorized Official

Name: MR. ROBERT STAROSTA
Title or Position: CEO
Credential:
Phone: 952-837-9754