Organization
MID AMERICA RADIOLOGY SC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
JERROLD C WILLIS MD (PRESIDENT)
(618) 242-4600
Entity
Organization
Contact information
Practice address
1 GOOD SAMARITAN WAY, RADIOLOGY DEPT, MOUNT VERNON, IL 62864-2402
(618) 242-4600
Mailing address
PO BOX 2153 DEPT 20002, BIRMINGHAM, AL 35287-0001
(303) 465-0401
(303) 438-1351
Taxonomy
Speciality
Code
Description
License number
State
2085R0202X
Diagnostic Radiology Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
CB6407
RR/ GOOD SAM & ST MARY'S
IL
01
—
CB6408
RR/ ST JOE & UTLAH
IL
Enumeration date
05/23/2006
Last updated
03/15/2021
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