=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700820560
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SALT CREEK MEDICAL IMAGING, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/15/2006
-----------------------------------------------------
Last Update Date | 07/18/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 777 OAKMONT LN STE. 1200
-----------------------------------------------------
City | WESTMONT
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60559-5511
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-413-4490
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 777 OAKMONT LN STE. 1200
-----------------------------------------------------
City | WESTMONT
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60559-5511
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-413-4490
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | MAHESH PURI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 630-413-4490
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085N0700X
-----------------------------------------------------
Taxonomy Name | Neuroradiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2085N0904X
-----------------------------------------------------
Taxonomy Name | Nuclear Radiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 2085P0229X
-----------------------------------------------------
Taxonomy Name | Pediatric Radiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 261QR0200X
-----------------------------------------------------
Taxonomy Name | Radiology Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------