Provider Demographics
NPI:1669742623
Name:LIBERTY DIAGNOSTIC SERVICES
Entity type:Organization
Organization Name:LIBERTY DIAGNOSTIC SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:COLLETT
Authorized Official - Suffix:
Authorized Official - Credentials:RDMS
Authorized Official - Phone:815-338-2411
Mailing Address - Street 1:518 S HIGHWAY 31
Mailing Address - Street 2:
Mailing Address - City:MCHENRY
Mailing Address - State:IL
Mailing Address - Zip Code:60050-7464
Mailing Address - Country:US
Mailing Address - Phone:815-338-2411
Mailing Address - Fax:
Practice Address - Street 1:518 S HIGHWAY 31
Practice Address - Street 2:
Practice Address - City:MCHENRY
Practice Address - State:IL
Practice Address - Zip Code:60050-7464
Practice Address - Country:US
Practice Address - Phone:815-338-2411
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-09
Last Update Date:2012-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2471S1302XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistSonographyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL6019701Medicaid
IL561510Medicare PIN