MEDICARE: MERIDIAN REGIONAL IMAGING,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	2085R0202X	Diagnostic Radiology Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	4932299	OTHER	IL	BLUE SHIELD

General Provider Information

NPI Number	:	1831145820
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MERIDIAN REGIONAL IMAGING,LLC

Provider Business Mailing Address
First Line	:	1035 CAMPUS DR
Second Line	:
City	:	MUNDELEIN
State	:	IL
Zip	:	60060-3834
Country	:	US
Telephone Number	:	847-816-3007
Fax Number	:

Provider Business Practice Location Address
First Line	:	1035 CAMPUS DR
Second Line	:
City	:	MUNDELEIN
State	:	IL
Zip	:	60060-3834
Country	:	US
Telephone Number	:	847-816-3007
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	LARRY ANDREW RANAHAN
Credential	:
Telephone Number	:	847-816-3007

Provider Enumeration Date	:	05/25/2006
Last Update Date	:	10/02/2007

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