Organization
CENTRAL ILLINOIS NEURORADIOLOGY, LTD
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. DEXTER HALL (MANAGER)
(314) 821-5600
Entity
Organization
Contact information
Practice address
1709 JUMER DR, SUITE B, BLOOMINGTON, IL 61704-0909
(309) 664-6808
(309) 664-6809
Mailing address
1715 DEER TRACKS TRL, SUITE 130, SAINT LOUIS, MO 63131-1839
(314) 821-5600
(314) 821-2180
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
—
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
5723741
BCBS GROUP #
IL
01
—
CH0689
RAILROAD MEDICARE GROUP #
IL
Enumeration date
05/28/2006
Last updated
10/23/2007
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