Provider Demographics
NPI:1730218652
Name:RADIOLOGIC INTERPRETATIONS OF SOUTHERN ILLINOIS LTD
Entity type:Organization
Organization Name:RADIOLOGIC INTERPRETATIONS OF SOUTHERN ILLINOIS LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:L
Authorized Official - Last Name:FULK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-529-8500
Mailing Address - Street 1:1200 CEDAR COURT
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62901-5334
Mailing Address - Country:US
Mailing Address - Phone:618-529-8500
Mailing Address - Fax:618-549-1000
Practice Address - Street 1:1200 CEDAR COURT
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-5334
Practice Address - Country:US
Practice Address - Phone:618-529-8500
Practice Address - Fax:618-549-1000
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-05
Last Update Date:2015-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes247100000XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILG73890Medicare UPIN