Provider Demographics
NPI:1205831971
Name:LOGAN PARK IMAGING LLC
Entity Type:Organization
Organization Name:LOGAN PARK IMAGING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:WROPHAS
Authorized Official - Middle Name:
Authorized Official - Last Name:MEEKS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-998-9633
Mailing Address - Street 1:500 LINCOLN DR
Mailing Address - Street 2:STE C
Mailing Address - City:HERRIN
Mailing Address - State:IL
Mailing Address - Zip Code:62948-6334
Mailing Address - Country:US
Mailing Address - Phone:618-998-9633
Mailing Address - Fax:618-998-9623
Practice Address - Street 1:500 LINCOLN DR
Practice Address - Street 2:STE C
Practice Address - City:HERRIN
Practice Address - State:IL
Practice Address - Zip Code:62948-6334
Practice Address - Country:US
Practice Address - Phone:618-998-9633
Practice Address - Fax:618-998-9623
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-17
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL703280Medicare ID - Type UnspecifiedMEDICARE GROUP #