MEDICARE: REGIONAL DIAGNOSTICS, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QR0200X	Radiology Clinic/Center		IL

General Provider Information

NPI Number	:	1053309377
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	REGIONAL DIAGNOSTICS, LLC

Provider Business Mailing Address
First Line	:	4400 RENAISSANCE PKWY
Second Line	:
City	:	WARRENSVILLE HTS.
State	:	OH
Zip	:	44128-5763
Country	:	US
Telephone Number	:	216-464-8484
Fax Number	:	216-468-6021

Provider Business Practice Location Address
First Line	:	4351 N CICERO AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60641-1502
Country	:	US
Telephone Number	:	773-427-1222
Fax Number	:	773-427-1333

Authorized Official
Title or Position	:	C.F.O.
Name	:	MR. RON CLARK
Credential	:
Telephone Number	:	216-464-8484

Provider Enumeration Date	:	10/11/2005
Last Update Date	:	08/22/2020

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