Provider Demographics
NPI:1235204322
Name:IMAGING CENTER OF SALEM, INC
Entity Type:Organization
Organization Name:IMAGING CENTER OF SALEM, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MNGR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LU
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:BOGOLIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-966-6070
Mailing Address - Street 1:PO BOX 31249
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63131-0249
Mailing Address - Country:US
Mailing Address - Phone:314-966-6070
Mailing Address - Fax:314-966-3440
Practice Address - Street 1:1325D W WHITTAKER ST
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:IL
Practice Address - Zip Code:62881
Practice Address - Country:US
Practice Address - Phone:618-548-3796
Practice Address - Fax:618-548-3050
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-22
Last Update Date:2009-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207RM1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RM1200XAllopathic & Osteopathic PhysiciansInternal MedicineMagnetic Resonance Imaging (MRI)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL06130188OtherBCBS
IL470001830OtherRR MEDICARE
IL=========OtherTRICARE
IL470001830OtherRR MEDICARE
IL=========OtherTRICARE