Provider Demographics
NPI:1497857593
Name:BELLEVILLE IMAGING, INC.
Entity Type:Organization
Organization Name:BELLEVILLE IMAGING, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:R
Authorized Official - Last Name:HORACE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-233-9729
Mailing Address - Street 1:15 PARK PL
Mailing Address - Street 2:
Mailing Address - City:SWANSEA
Mailing Address - State:IL
Mailing Address - Zip Code:62226-2968
Mailing Address - Country:US
Mailing Address - Phone:618-233-9729
Mailing Address - Fax:
Practice Address - Street 1:15 PARK PL
Practice Address - Street 2:
Practice Address - City:SWANSEA
Practice Address - State:IL
Practice Address - Zip Code:62226-2968
Practice Address - Country:US
Practice Address - Phone:618-233-9729
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-01
Last Update Date:2009-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL364970261QR0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0206XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mammography
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL206290Medicare ID - Type UnspecifiedPROVIDER NUMBER