Provider Demographics
NPI:1467409540
Name:MOLECULAR IMAGING OF SUBURBAN CHICAGO, LLC
Entity Type:Organization
Organization Name:MOLECULAR IMAGING OF SUBURBAN CHICAGO, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:TUCKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-755-4327
Mailing Address - Street 1:3 GRANT SQUARE
Mailing Address - Street 2:SUITE 322
Mailing Address - City:HINSDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60521-3635
Mailing Address - Country:US
Mailing Address - Phone:630-325-6300
Mailing Address - Fax:630-214-2362
Practice Address - Street 1:230 EAST OGDEN AVENUE
Practice Address - Street 2:SUITE 100
Practice Address - City:HINSDALE
Practice Address - State:IL
Practice Address - Zip Code:60521-3635
Practice Address - Country:US
Practice Address - Phone:630-325-6300
Practice Address - Fax:360-214-2362
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-27
Last Update Date:2016-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0227301261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0002232827OtherBLUE CROSS BLUE SHIELD
IL21277392246OtherBEECH STREET
IL7435790OtherAETNA
ILILA10OtherONE CALL MEDICAL
IL0002232827OtherBLUE CROSS BLUE SHIELD