Provider Demographics
NPI:1114019312
Name:SOUTHERN ILLINOIS IMAGING ASSOCIATES, LLC
Entity Type:Organization
Organization Name:SOUTHERN ILLINOIS IMAGING ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:D
Authorized Official - Last Name:O'BRIEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:513-281-3400
Mailing Address - Street 1:509 HAMACHER ST
Mailing Address - Street 2:SUITE 300
Mailing Address - City:WATERLOO
Mailing Address - State:IL
Mailing Address - Zip Code:62298-1592
Mailing Address - Country:US
Mailing Address - Phone:618-939-9790
Mailing Address - Fax:
Practice Address - Street 1:509 HAMACHER ST
Practice Address - Street 2:SUITE 300
Practice Address - City:WATERLOO
Practice Address - State:IL
Practice Address - Zip Code:62298-1592
Practice Address - Country:US
Practice Address - Phone:618-939-9790
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2008-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL06732037OtherBC/BS PIN
7829963OtherAETNA PIN
IL06732037OtherBC/BS PIN
P00407886Medicare PIN