Provider Demographics
NPI:1386659241
Name:CENTRAL ILLINOIS RADIOLOGICAL ASSOCIATES, LTD.
Entity Type:Organization
Organization Name:CENTRAL ILLINOIS RADIOLOGICAL ASSOCIATES, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:FRASER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:309-494-9320
Mailing Address - Street 1:411 HAMILTON BLVD
Mailing Address - Street 2:SUITE 1824
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61602-1144
Mailing Address - Country:US
Mailing Address - Phone:309-494-9320
Mailing Address - Fax:309-494-9321
Practice Address - Street 1:OSF ST FRANCIS MEDICAL CTR
Practice Address - Street 2:530 N.E. GLEN OAK
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61636-0001
Practice Address - Country:US
Practice Address - Phone:309-655-4934
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL589050Medicare ID - Type UnspecifiedMEDICARE GROUP ID