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General NPI Number Information
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NPI Number | 1720197601
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Entity Type | Organization
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Legal Business Name | PROVENA IMAGING SERVICES INC
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Dates
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Enumeration Date | 08/30/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 100 PROVENA WAY SUITE 104
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City | BOURBONNAIS
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State | IL
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Zip | 60914
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Country | US
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Telephone | 815-929-5800
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Fax | 815-929-5801
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Provider Business Mailing Address
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Address Line | 5775 WAYZATA BLVD SUITE 400
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City | ST LOUIS PARK
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State | MN
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Zip | 55416
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Country | US
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Telephone | 952-542-8553
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Fax | 952-513-6880
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Authorized Official
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Title or Position | PRESIDENT
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Name | EDWARD MOLARE
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Credential |
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Telephone | 815-806-2309
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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 |
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