Provider Demographics
NPI:1427041086
Name:LIBERTYVILLE IMAGING ASSOCIATES, INC
Entity Type:Organization
Organization Name:LIBERTYVILLE IMAGING ASSOCIATES, INC
Other - Org Name:LIBERTYVILLE IMAGING CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:SHOUKATH
Authorized Official - Middle Name:
Authorized Official - Last Name:AHMED
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-549-8000
Mailing Address - Street 1:333 PETERSON RD
Mailing Address - Street 2:SUITE 230
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-1085
Mailing Address - Country:US
Mailing Address - Phone:847-549-8000
Mailing Address - Fax:847-549-8080
Practice Address - Street 1:333 PETERSON RD
Practice Address - Street 2:SUITE 230
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-1085
Practice Address - Country:US
Practice Address - Phone:847-549-8000
Practice Address - Fax:847-549-8080
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-29
Last Update Date:2014-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL207039Medicare PIN