Provider Demographics
NPI:1306583174
Name:DIASPORA RADIOLOGY, SC
Entity type:Organization
Organization Name:DIASPORA RADIOLOGY, SC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:
Authorized Official - Last Name:CORONA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:855-694-3300
Mailing Address - Street 1:PO BOX 772555
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48277-2620
Mailing Address - Country:US
Mailing Address - Phone:314-238-5260
Mailing Address - Fax:314-821-1833
Practice Address - Street 1:3004 GOLF RD STE 101
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-8794
Practice Address - Country:US
Practice Address - Phone:855-694-3300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DIASPORA RADIOLOGY, SC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-05-13
Last Update Date:2024-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty