Provider Demographics
NPI:1740406107
Name:SUBURBAN DIAGNOSTIC INC
Entity Type:Organization
Organization Name:SUBURBAN DIAGNOSTIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:
Authorized Official - Last Name:PADILLA
Authorized Official - Suffix:
Authorized Official - Credentials:RT
Authorized Official - Phone:815-577-8200
Mailing Address - Street 1:11600 LEGACY DR
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60585-5194
Mailing Address - Country:US
Mailing Address - Phone:815-577-8200
Mailing Address - Fax:815-577-8300
Practice Address - Street 1:11600 LEGACY DR
Practice Address - Street 2:
Practice Address - City:PLAINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60585-5194
Practice Address - Country:US
Practice Address - Phone:815-577-8200
Practice Address - Fax:815-577-8300
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2012-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL500483643335V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335V00000XSuppliersPortable X-ray and/or Other Portable Diagnostic Imaging Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL364369726001Medicaid
IL09932186OtherBCBS
IL09932186OtherBCBS