Provider Demographics
NPI:1295031706
Name:PROFESSIONAL RADIOLOGY AND EDX LLC
Entity Type:Organization
Organization Name:PROFESSIONAL RADIOLOGY AND EDX LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:RODRIGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-445-8218
Mailing Address - Street 1:655 W IRVING PARK RD
Mailing Address - Street 2:APT 2602
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613-3123
Mailing Address - Country:US
Mailing Address - Phone:321-445-8218
Mailing Address - Fax:
Practice Address - Street 1:655 W IRVING PARK RD
Practice Address - Street 2:APT 2602
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60613-3123
Practice Address - Country:US
Practice Address - Phone:321-445-8218
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-31
Last Update Date:2011-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty