Provider Demographics
NPI:1023241742
Name:CENTRAL ILLINOIS DIAGNOSTIC IMAGING CENTER, LLC
Entity type:Organization
Organization Name:CENTRAL ILLINOIS DIAGNOSTIC IMAGING CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:SEIBERT
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MS
Authorized Official - Phone:217-398-4594
Mailing Address - Street 1:1804 BENTBROOK DR
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61822-9218
Mailing Address - Country:US
Mailing Address - Phone:217-352-2711
Mailing Address - Fax:
Practice Address - Street 1:3002 CROSSING CT
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61822-6135
Practice Address - Country:US
Practice Address - Phone:217-398-4594
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-27
Last Update Date:2016-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL021001261261QD0000X, 261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental