Provider Demographics
NPI:1306011846
Name:IMAGING CENTER OF SALEM
Entity Type:Organization
Organization Name:IMAGING CENTER OF SALEM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MNGR
Authorized Official - Prefix:MR
Authorized Official - First Name:LU
Authorized Official - Middle Name:
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 1:1325 W WHITTAKER ST STE D
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:IL
Practice Address - Zip Code:62881-2034
Practice Address - Country:US
Practice Address - Phone:618-548-3796
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-25
Last Update Date:2008-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RM1200XAllopathic & Osteopathic PhysiciansInternal MedicineMagnetic Resonance Imaging (MRI)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1235204322OtherNPI 1ST # GIVEN
IL427080OtherHEALTHLINK
IL06130188OtherBLUE CROSS/BLUE SHIELD
IL427080OtherHEALTHLINK
IL06130188OtherBLUE CROSS/BLUE SHIELD