Provider Demographics
NPI:1538192828
Name:CENTRAL ILLINOIS RADIOLOGICAL ASSOCIATES, LTD.
Entity type:Organization
Organization Name:CENTRAL ILLINOIS RADIOLOGICAL ASSOCIATES, LTD.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:FAHEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:309-740-4272
Mailing Address - Street 1:111 OAKWOOD RD
Mailing Address - Street 2:
Mailing Address - City:EAST PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61611-1853
Mailing Address - Country:US
Mailing Address - Phone:309-740-4272
Mailing Address - Fax:309-740-7479
Practice Address - Street 1:530 NE GLEN OAK AVENUE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61637
Practice Address - Country:US
Practice Address - Phone:309-740-4272
Practice Address - Fax:309-740-7479
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2020-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID589050Medicare PIN