Provider Demographics
NPI:1538497920
Name:CHICAGO RIDGE RADIOLOGY SC
Entity Type:Organization
Organization Name:CHICAGO RIDGE RADIOLOGY SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ABDUL
Authorized Official - Middle Name:
Authorized Official - Last Name:AMINE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-430-3350
Mailing Address - Street 1:2448 S 102ND ST
Mailing Address - Street 2:STE 125
Mailing Address - City:WEST ALLIS
Mailing Address - State:WI
Mailing Address - Zip Code:53227-2466
Mailing Address - Country:US
Mailing Address - Phone:414-328-3800
Mailing Address - Fax:414-328-3818
Practice Address - Street 1:9830 RIDGELAND AVE
Practice Address - Street 2:STE 8
Practice Address - City:CHICAGO RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60415-2667
Practice Address - Country:US
Practice Address - Phone:708-423-1819
Practice Address - Fax:708-423-4788
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-24
Last Update Date:2010-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL3020Medicare PIN