Healthcare Provider Details

I. General information

NPI: 1104166966
Provider Name (Legal Business Name): SUBURBAN DIAGNOSTIC CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2013
Last Update Date: 02/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3830 WOODLEY RD SUITE A
TOLEDO OH
43606-1177
US

IV. Provider business mailing address

3830 WOODLEY RD SUITE A
TOLEDO OH
43606-1177
US

V. Phone/Fax

Practice location:
  • Phone: 419-841-7766
  • Fax:
Mailing address:
  • Phone: 419-841-7766
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0206X
TaxonomyMammography Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ALLIE GALOVICH
Title or Position: BILLER
Credential: CPC
Phone: 248-593-9780