Provider Demographics
NPI:1386755700
Name:FOREST CITY DIAGNOSTIC IMAGING LLC
Entity type:Organization
Organization Name:FOREST CITY DIAGNOSTIC IMAGING LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:A
Authorized Official - Last Name:WABICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-675-1500
Mailing Address - Street 1:735 N PERRYVILLE RD
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-6200
Mailing Address - Country:US
Mailing Address - Phone:815-398-1300
Mailing Address - Fax:815-398-3797
Practice Address - Street 1:735 N PERRYVILLE RD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-6200
Practice Address - Country:US
Practice Address - Phone:815-398-1300
Practice Address - Fax:815-398-3797
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2019-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
10123287OtherBC BS
470000357OtherRAILROAD MEDICARE
10123287OtherBC BS
=========002OtherTRICARE
IL546450Medicare ID - Type Unspecified