Provider Demographics
NPI:1518131606
Name:METROPOLITAN DIAGNOSTIC IMAGING
Entity Type:Organization
Organization Name:METROPOLITAN DIAGNOSTIC IMAGING
Other - Org Name:AMIC MERRIONETTE PARK
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ACCT RECEIVABLE
Authorized Official - Prefix:MS
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-807-3550
Mailing Address - Street 1:111 N WABASH AVE STE 620
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60602-1914
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11600 S KEDZIE AVE
Practice Address - Street 2:
Practice Address - City:MERRIONETTE PARK
Practice Address - State:IL
Practice Address - Zip Code:60803-6302
Practice Address - Country:US
Practice Address - Phone:708-377-3730
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-18
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL21621866OtherBLUE CROSS BLUE SHIELD
IL=========003Medicaid
IL=========003Medicaid