Provider Demographics
NPI:1164548756
Name:LINCOLN PARK OPEN MRI, LLC
Entity Type:Organization
Organization Name:LINCOLN PARK OPEN MRI, LLC
Other - Org Name:LAKE SHORE OPEN MRI & CT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RAGHU
Authorized Official - Middle Name:
Authorized Official - Last Name:NAYAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-761-0200
Mailing Address - Street 1:7200 N WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60645-1812
Mailing Address - Country:US
Mailing Address - Phone:773-761-0200
Mailing Address - Fax:773-761-0202
Practice Address - Street 1:7200 N WESTERN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60645-1812
Practice Address - Country:US
Practice Address - Phone:773-761-0200
Practice Address - Fax:773-761-0202
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========OtherTAX ID #