Provider Demographics
NPI:1629027594
Name:SUBURBAN RADIOLOGIC CONSULTANTS, LTD.
Entity Type:Organization
Organization Name:SUBURBAN RADIOLOGIC CONSULTANTS, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:STAROSTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-837-9754
Mailing Address - Street 1:2355 HWY 36 W.
Mailing Address - Street 2:STE. 100
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113
Mailing Address - Country:US
Mailing Address - Phone:651-292-2000
Mailing Address - Fax:
Practice Address - Street 1:2355 HWY 36 W.
Practice Address - Street 2:STE. 100
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113-5511
Practice Address - Country:US
Practice Address - Phone:651-292-2000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-09
Last Update Date:2020-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN261261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT0958OtherRAILROAD MEDICARE
MN5077087-00Medicaid