Organization
SOUTHWEST RADIOLOGIST JOINT VTR
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. PATTY MANCUSO (OFFICE MANAGER)
(708) 388-0423
Entity
Organization
Contact information
Practice address
5550 W 111TH ST, OAK LAWN, IL 60453-5012
(708) 636-0633
(708) 636-0689
Mailing address
3300 127TH ST, 2ND FLOOR, BLUE ISLAND, IL 60406-3802
(708) 388-0423
(708) 388-1477
Taxonomy
Speciality
Code
Description
License number
State
2085R0202X
Diagnostic Radiology Physician
Primary
—
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
01617844
BCBS GROUP
IL
01
—
CB4562
TRAVELERS MEDICARE GRP
IL
Enumeration date
06/11/2006
Last updated
07/21/2022
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