MEDICARE: SUBURBAN DIAGNOSTIC CLINIC 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	261QR0206X	Mammography Clinic/Center
2	261QR0200X	Radiology Clinic/Center

General Provider Information

NPI Number	:	1104166966
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUBURBAN DIAGNOSTIC CLINIC LLC

Provider Business Mailing Address
First Line	:	3830 WOODLEY RD
Second Line	:	SUITE A
City	:	TOLEDO
State	:	OH
Zip	:	43606-1177
Country	:	US
Telephone Number	:	419-841-7766
Fax Number	:

Provider Business Practice Location Address
First Line	:	3830 WOODLEY RD
Second Line	:	SUITE A
City	:	TOLEDO
State	:	OH
Zip	:	43606-1177
Country	:	US
Telephone Number	:	419-841-7766
Fax Number	:

Authorized Official
Title or Position	:	BILLER
Name	:	ALLIE GALOVICH
Credential	:	CPC
Telephone Number	:	248-593-9780

Provider Enumeration Date	:	02/15/2013
Last Update Date	:	02/15/2013

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