Provider Demographics
NPI:1316057334
Name:WELLINGTON RADIOLOGY GROUP, S.C.
Entity type:Organization
Organization Name:WELLINGTON RADIOLOGY GROUP, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SPR
Authorized Official - Middle Name:
Authorized Official - Last Name:NAOIMPALLI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-296-7820
Mailing Address - Street 1:39006 TREASURY CENTER
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60694-9000
Mailing Address - Country:US
Mailing Address - Phone:708-460-7444
Mailing Address - Fax:708-460-8662
Practice Address - Street 1:836 WEST WELLINGTON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657
Practice Address - Country:US
Practice Address - Phone:773-296-7820
Practice Address - Fax:773-296-7821
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1635352OtherBCBS
IL211655Medicare ID - Type Unspecified
IL1635352OtherBCBS