Provider Demographics
NPI:1346228848
Name:TRI COUNTY RADIOLOGY
Entity Type:Organization
Organization Name:TRI COUNTY RADIOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CMPE, CHBC
Authorized Official - Prefix:MR
Authorized Official - First Name:W
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:COOPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-682-7750
Mailing Address - Street 1:PO BOX 3853
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61612-3853
Mailing Address - Country:US
Mailing Address - Phone:800-899-5757
Mailing Address - Fax:314-821-1833
Practice Address - Street 1:5409 N KNOXVILLE AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61615
Practice Address - Country:US
Practice Address - Phone:309-682-7750
Practice Address - Fax:309-682-7786
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody ImagingGroup - Multi-Specialty
Not Answered2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear RadiologyGroup - Multi-Specialty
Not Answered2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Multi-Specialty
Not Answered2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic UltrasoundGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0007222342OtherBLUE CROSS BLUE SHIELD
ILIL0100OtherJOHN DEERE
ILIL0100OtherJOHN DEERE
IL0007222342OtherBLUE CROSS BLUE SHIELD