Provider Demographics
NPI:1225563380
Name:ROUND LAKE MEDICAL IMAGING INC
Entity Type:Organization
Organization Name:ROUND LAKE MEDICAL IMAGING INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:
Authorized Official - Last Name:THENGANATT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-922-6306
Mailing Address - Street 1:720 E ROLLINS RD
Mailing Address - Street 2:
Mailing Address - City:ROUND LAKE BEACH
Mailing Address - State:IL
Mailing Address - Zip Code:60073-1340
Mailing Address - Country:US
Mailing Address - Phone:847-546-3600
Mailing Address - Fax:
Practice Address - Street 1:720 E ROLLINS RD
Practice Address - Street 2:
Practice Address - City:ROUND LAKE BEACH
Practice Address - State:IL
Practice Address - Zip Code:60073-1340
Practice Address - Country:US
Practice Address - Phone:847-546-3600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-26
Last Update Date:2017-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL500505334261QM1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)