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General NPI Number Information
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NPI Number | 1245287143
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Entity Type | Organization
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Legal Business Name | FT. JESSE IMAGING CENTER LLC
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Dates
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Enumeration Date | 05/27/2006
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Last Update Date | 10/21/2024
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Provider Practice Location Address
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Address Line | 2200 FORT JESSE RD SUITE 130
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City | NORMAL
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State | IL
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Zip | 61761-6286
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Country | US
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Telephone | 309-454-5552
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Fax | 309-454-5452
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Provider Business Mailing Address
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Address Line | 2200 FORT JESSE RD SUITE 130
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City | NORMAL
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State | IL
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Zip | 61761-6286
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Country | US
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Telephone | 309-454-5552
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Fax | 309-454-5452
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Authorized Official
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Title or Position | PRESIDENT/CEO
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Name | AMY STOUT
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Credential |
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Telephone | 615-261-2306
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR0200X
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Taxonomy Name | Radiology Clinic/Center
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License Number | 9256804
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 261QR0206X
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Taxonomy Name | Mammography Clinic/Center
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License Number | 9256804
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License Number State | IL
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Taxonomy #3
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number |
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License Number State |
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