Provider Demographics
NPI:1053309377
Name:REGIONAL DIAGNOSTICS, LLC
Entity Type:Organization
Organization Name:REGIONAL DIAGNOSTICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:C.F.O.
Authorized Official - Prefix:MR
Authorized Official - First Name:RON
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:216-464-8484
Mailing Address - Street 1:4400 RENAISSANCE PKWY
Mailing Address - Street 2:
Mailing Address - City:WARRENSVILLE HTS.
Mailing Address - State:OH
Mailing Address - Zip Code:44128-5763
Mailing Address - Country:US
Mailing Address - Phone:216-464-8484
Mailing Address - Fax:216-468-6021
Practice Address - Street 1:4351 N CICERO AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60641-1502
Practice Address - Country:US
Practice Address - Phone:773-427-1222
Practice Address - Fax:773-427-1333
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========004Medicaid
IL=========004Medicaid