Provider Demographics
NPI:1790402543
Name:DIASPORA RADIOLOGY, SC
Entity Type:Organization
Organization Name:DIASPORA RADIOLOGY, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR DIRECTOR, OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:
Authorized Official - Last Name:CORONA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-878-9109
Mailing Address - Street 1:1914 PINE DR
Mailing Address - Street 2:
Mailing Address - City:MCHENRY
Mailing Address - State:IL
Mailing Address - Zip Code:60051-2620
Mailing Address - Country:US
Mailing Address - Phone:847-878-9109
Mailing Address - Fax:
Practice Address - Street 1:111 SAND LAKE RD
Practice Address - Street 2:
Practice Address - City:ONALASKA
Practice Address - State:WI
Practice Address - Zip Code:54650-2760
Practice Address - Country:US
Practice Address - Phone:847-878-9109
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DIASPORA RADIOLOGY, SC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-10-24
Last Update Date:2022-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty