Provider Demographics
NPI:1003933920
Name:MIDWEST DIAGNOSTIC MANAGEMENT, LLC
Entity Type:Organization
Organization Name:MIDWEST DIAGNOSTIC MANAGEMENT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:JON
Authorized Official - Middle Name:
Authorized Official - Last Name:KNIPPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-478-6434
Mailing Address - Street 1:19065 HICKORY CREEK PL
Mailing Address - Street 2:SUITE 240
Mailing Address - City:MOKENA
Mailing Address - State:IL
Mailing Address - Zip Code:60448-8507
Mailing Address - Country:US
Mailing Address - Phone:708-478-6417
Mailing Address - Fax:708-535-8087
Practice Address - Street 1:19065 HICKORY CREEK PL
Practice Address - Street 2:SUITE 240
Practice Address - City:MOKENA
Practice Address - State:IL
Practice Address - Zip Code:60448-8507
Practice Address - Country:US
Practice Address - Phone:708-478-6417
Practice Address - Fax:708-535-8087
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-24
Last Update Date:2008-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization