MEDICARE: CT SCAN CENTER, INC.

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	2085R0202X	Diagnostic Radiology Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1750501987
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CT SCAN CENTER, INC.

Provider Business Mailing Address
First Line	:	112 E CLARK ST
Second Line	:
City	:	HARRISBURG
State	:	IL
Zip	:	62946-2703
Country	:	US
Telephone Number	:	618-252-8337
Fax Number	:	618-252-8338

Provider Business Practice Location Address
First Line	:	112 E CLARK ST
Second Line	:
City	:	HARRISBURG
State	:	IL
Zip	:	62946-2703
Country	:	US
Telephone Number	:	618-252-8337
Fax Number	:	618-252-8338

Authorized Official
Title or Position	:	RADIOLOGIST
Name	:	HISHAM T YOUSSEF
Credential	:	MD
Telephone Number	:	618-252-8337

Provider Enumeration Date	:	04/30/2007
Last Update Date	:	04/23/2018

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