Provider Demographics
NPI:1437276508
Name:INMED DIAGNOSTIC SERVICES OF IL LLC
Entity Type:Organization
Organization Name:INMED DIAGNOSTIC SERVICES OF IL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:LONGTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-510-3704
Mailing Address - Street 1:2400 E COMMERCIAL BLVD
Mailing Address - Street 2:SUITE 826
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33308-4054
Mailing Address - Country:US
Mailing Address - Phone:954-510-3700
Mailing Address - Fax:954-510-2649
Practice Address - Street 1:10419 FLEMING RD
Practice Address - Street 2:
Practice Address - City:CARTERVILLE
Practice Address - State:IL
Practice Address - Zip Code:62918-3391
Practice Address - Country:US
Practice Address - Phone:618-985-8007
Practice Address - Fax:618-985-8031
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-23
Last Update Date:2014-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL=========001Medicaid