Provider Demographics
NPI:1306016530
Name:MOLECULAR IMAGING OF WOOD DALE, LLC
Entity Type:Organization
Organization Name:MOLECULAR IMAGING OF WOOD DALE, LLC
Other - Org Name:SAME
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ALICE
Authorized Official - Middle Name:
Authorized Official - Last Name:GARDNER
Authorized Official - Suffix:
Authorized Official - Credentials:MPH
Authorized Official - Phone:630-325-6300
Mailing Address - Street 1:199 S ADDISON RD
Mailing Address - Street 2:STE 107B
Mailing Address - City:WOOD DALE
Mailing Address - State:IL
Mailing Address - Zip Code:60191-1929
Mailing Address - Country:US
Mailing Address - Phone:630-694-6300
Mailing Address - Fax:630-325-6390
Practice Address - Street 1:199 S ADDISON RD
Practice Address - Street 2:STE 107B
Practice Address - City:WOOD DALE
Practice Address - State:IL
Practice Address - Zip Code:60191-1929
Practice Address - Country:US
Practice Address - Phone:630-694-6300
Practice Address - Fax:630-325-6390
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-04
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========OtherTAX ID