Provider Demographics
NPI:1285790519
Name:THE CARBONDALE CLINIC RADIOLOGY
Entity type:Organization
Organization Name:THE CARBONDALE CLINIC RADIOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:ALLAN
Authorized Official - Middle Name:N
Authorized Official - Last Name:NORMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-457-5200
Mailing Address - Street 1:2601 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62901-1031
Mailing Address - Country:US
Mailing Address - Phone:618-457-5200
Mailing Address - Fax:618-549-5128
Practice Address - Street 1:2601 W MAIN ST
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-1031
Practice Address - Country:US
Practice Address - Phone:618-457-5200
Practice Address - Fax:618-549-5128
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE CARBONDALE CLINIC, S.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-29
Last Update Date:2008-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL614350OtherLEGACY
IL044651OtherHAMP
IL464790OtherHEALTHLINK
IL690006448OtherRR MEDICARE
IL196090OtherGHP
IL044651OtherHAMP
IL=========009Medicaid