Provider Demographics
NPI:1881641371
Name:CENTRAL ILLINOIS NEURORADIOLOGY, LTD
Entity Type:Organization
Organization Name:CENTRAL ILLINOIS NEURORADIOLOGY, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:DEXTER
Authorized Official - Middle Name:
Authorized Official - Last Name:HALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-821-5600
Mailing Address - Street 1:1715 DEER TRACKS TRL
Mailing Address - Street 2:SUITE 130
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63131-1839
Mailing Address - Country:US
Mailing Address - Phone:314-821-5600
Mailing Address - Fax:314-821-2180
Practice Address - Street 1:1709 JUMER DR
Practice Address - Street 2:SUITE B
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-0909
Practice Address - Country:US
Practice Address - Phone:309-664-6808
Practice Address - Fax:309-664-6809
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-28
Last Update Date:2007-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL5723741OtherBCBS GROUP #
ILCH0689OtherRAILROAD MEDICARE GROUP #
ILCH0689OtherRAILROAD MEDICARE GROUP #