Provider Demographics
NPI:1700831773
Name:BLOOMINGTON RADIOLOGY S C
Entity Type:Organization
Organization Name:BLOOMINGTON RADIOLOGY S C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:AJAY
Authorized Official - Middle Name:
Authorized Official - Last Name:MALPANI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:309-452-1788
Mailing Address - Street 1:PO BOX 3668
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61702-3668
Mailing Address - Country:US
Mailing Address - Phone:309-452-1788
Mailing Address - Fax:309-862-1302
Practice Address - Street 1:2200 FORT JESSE RD
Practice Address - Street 2:SUITE 280
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-6286
Practice Address - Country:US
Practice Address - Phone:309-452-1788
Practice Address - Fax:309-862-1302
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-24
Last Update Date:2021-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0420017552085B0100X, 2085N0700X, 2085N0904X, 2085R0202X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody ImagingGroup - Single Specialty
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiologyGroup - Single Specialty
No2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear RadiologyGroup - Single Specialty
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL274220Medicare PIN