Provider Demographics
NPI:1720197601
Name:PROVENA IMAGING SERVICES INC
Entity Type:Organization
Organization Name:PROVENA IMAGING SERVICES INC
Other - Org Name:PROVENA HEALTH CENTER FOR DIAGNOSTIC IMAGING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:MOLARE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-806-2309
Mailing Address - Street 1:5775 WAYZATA BLVD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416
Mailing Address - Country:US
Mailing Address - Phone:952-542-8553
Mailing Address - Fax:952-513-6880
Practice Address - Street 1:100 PROVENA WAY
Practice Address - Street 2:SUITE 104
Practice Address - City:BOURBONNAIS
Practice Address - State:IL
Practice Address - Zip Code:60914
Practice Address - Country:US
Practice Address - Phone:815-929-5800
Practice Address - Fax:815-929-5801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty