Provider Demographics
NPI:1245283266
Name:CENTRAL STATES IMAGING LLC
Entity type:Organization
Organization Name:CENTRAL STATES IMAGING LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SPECIAL ASSISTANT SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:C
Authorized Official - Last Name:HOLMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-513-6831
Mailing Address - Street 1:PO BOX 1450
Mailing Address - Street 2:NW5710
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55485-5710
Mailing Address - Country:US
Mailing Address - Phone:952-542-8553
Mailing Address - Fax:952-513-6880
Practice Address - Street 1:4 CEDAR RIDGE DRIVE
Practice Address - Street 2:SUITE D
Practice Address - City:LAKE IN THE HILLS
Practice Address - State:IL
Practice Address - Zip Code:60156
Practice Address - Country:US
Practice Address - Phone:847-458-6736
Practice Address - Fax:847-458-6700
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-19
Last Update Date:2021-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL626710Medicare PIN