Provider Demographics
NPI:1528214855
Name:KONTZIALIS, MARINOS
Entity Type:Individual
Prefix:
First Name:MARINOS
Middle Name:
Last Name:KONTZIALIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:676 N SAINT CLAIR ST STE 1400
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2951
Mailing Address - Country:US
Mailing Address - Phone:312-695-1292
Mailing Address - Fax:312-695-3999
Practice Address - Street 1:676 N SAINT CLAIR ST STE 1400
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2951
Practice Address - Country:US
Practice Address - Phone:312-695-1292
Practice Address - Fax:312-695-3999
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-18
Last Update Date:2020-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-1387882085N0700X, 2085R0202X
IL0361387882085D0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085D0003XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Neuroimaging
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology