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General NPI Number Information
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NPI Number | 1316989973
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Entity Type | Organization
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Legal Business Name | SOUTHWEST RADIOLOGIST JOINT VTR
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Dates
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Enumeration Date | 06/11/2006
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 5550 W 111TH ST
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City | OAK LAWN
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State | IL
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Zip | 60453-5012
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Country | US
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Telephone | 708-636-0633
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Fax | 708-636-0689
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Provider Business Mailing Address
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Address Line | 3300 127TH ST 2ND FLOOR
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City | BLUE ISLAND
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State | IL
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Zip | 60406-3802
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Country | US
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Telephone | 708-388-0423
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Fax | 708-388-1477
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | MRS. PATTY MANCUSO
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Credential |
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Telephone | 708-388-0423
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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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 | IL
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