Provider Demographics
NPI:1033383831
Name:GURNEE RADIOLOGY CENTER, LLC
Entity Type:Organization
Organization Name:GURNEE RADIOLOGY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:ROSENGARTEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-918-1462
Mailing Address - Street 1:25 TOWER CT
Mailing Address - Street 2:SUITE A
Mailing Address - City:GURNEE
Mailing Address - State:IL
Mailing Address - Zip Code:60031-3318
Mailing Address - Country:US
Mailing Address - Phone:847-249-3700
Mailing Address - Fax:847-249-4880
Practice Address - Street 1:2151 WAUKEGAN RD
Practice Address - Street 2:SUITE 150
Practice Address - City:BANNOCKBURN
Practice Address - State:IL
Practice Address - Zip Code:60015-1885
Practice Address - Country:US
Practice Address - Phone:847-317-0011
Practice Address - Fax:847-317-0022
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-14
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========004Medicaid
ILCN5413Medicare PIN
IL621320Medicare PIN
IL309590Medicare PIN