Provider Demographics
NPI:1285667311
Name:GALESBURG RADIOLOGY ASSOCIATES, S.C.
Entity Type:Organization
Organization Name:GALESBURG RADIOLOGY ASSOCIATES, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SUBBIA
Authorized Official - Middle Name:
Authorized Official - Last Name:JAGANNATHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:877-852-4669
Mailing Address - Street 1:PO BOX 1093
Mailing Address - Street 2:
Mailing Address - City:BEDFORD PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60499-1093
Mailing Address - Country:US
Mailing Address - Phone:877-852-4669
Mailing Address - Fax:
Practice Address - Street 1:695 N KELLOGG ST
Practice Address - Street 2:
Practice Address - City:GALESBURG
Practice Address - State:IL
Practice Address - Zip Code:61401-2807
Practice Address - Country:US
Practice Address - Phone:877-852-4669
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2011-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL04815047OtherBLUE CROSS BLUE SHIELD
ILCM2090OtherRAILROAD MEDICARE
IL739680Medicare ID - Type Unspecified