Provider Demographics
NPI:1649238312
Name:ILLINOIS DIAGNOSTIC IMAGING, INC
Entity Type:Organization
Organization Name:ILLINOIS DIAGNOSTIC IMAGING, INC
Other - Org Name:SPRINGFIELD MRI & IMAGING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:SCHAEFER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-300-0101
Mailing Address - Street 1:PO BOX 934988
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:31193-4988
Mailing Address - Country:US
Mailing Address - Phone:866-659-1211
Mailing Address - Fax:336-774-1751
Practice Address - Street 1:319 E MADISON ST
Practice Address - Street 2:SUITE J
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62701-1035
Practice Address - Country:US
Practice Address - Phone:217-528-4770
Practice Address - Fax:217-528-2154
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-03
Last Update Date:2009-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0008432117OtherBC
P00164612OtherMEDICARE RR
IL0008432117OtherBC
IL206771Medicare PIN