Provider Demographics
NPI:1013046366
Name:SALEM FLORA RADIOLOGY, S.C.
Entity Type:Organization
Organization Name:SALEM FLORA RADIOLOGY, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PREECHA
Authorized Official - Middle Name:
Authorized Official - Last Name:TAWJAREON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-548-2843
Mailing Address - Street 1:815 W MAIN ST
Mailing Address - Street 2:P.O. BOX 875
Mailing Address - City:SALEM
Mailing Address - State:IL
Mailing Address - Zip Code:62881-1408
Mailing Address - Country:US
Mailing Address - Phone:618-548-2843
Mailing Address - Fax:618-548-2896
Practice Address - Street 1:815 W MAIN ST
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:IL
Practice Address - Zip Code:62881-1408
Practice Address - Country:US
Practice Address - Phone:618-548-2843
Practice Address - Fax:618-548-2896
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-05
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2085R0202X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILCF1003OtherRAILROAD MEDICARE
ILP04756OtherFLORA PIN #
IL0006115210OtherBLUECROSS BLUESHIELD
ILL06343OtherSALEM PIN #
ILP04756OtherFLORA PIN #
IL0006115210OtherBLUECROSS BLUESHIELD
ILL06343OtherSALEM PIN #