Provider Demographics
NPI:1033206271
Name:NORTHEAST RADIOLOGY ASSOCIATES, S.C.
Entity Type:Organization
Organization Name:NORTHEAST RADIOLOGY ASSOCIATES, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESEIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:DEBRUIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-535-6313
Mailing Address - Street 1:660 N WESTMORELAND RD
Mailing Address - Street 2:RADIOLOGY DEPARTMENT
Mailing Address - City:LAKE FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60045-1659
Mailing Address - Country:US
Mailing Address - Phone:847-535-6313
Mailing Address - Fax:
Practice Address - Street 1:660 N WESTMORELAND RD
Practice Address - Street 2:RADIOLOGY DEPARTMENT
Practice Address - City:LAKE FOREST
Practice Address - State:IL
Practice Address - Zip Code:60045-1659
Practice Address - Country:US
Practice Address - Phone:847-535-6313
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-09
Last Update Date:2007-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL4923631OtherBCBS ID
CH1744OtherRAILROAD ID
CH1744OtherRAILROAD ID