Provider Demographics
NPI:1609823038
Name:GALILEE MEDICAL CENTER, S.C.
Entity Type:Organization
Organization Name:GALILEE MEDICAL CENTER, S.C.
Other - Org Name:MRI LINCOLN IMAGING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:NASER
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSTOM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-237-0755
Mailing Address - Street 1:4941 N KEDZIE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-5009
Mailing Address - Country:US
Mailing Address - Phone:773-293-0451
Mailing Address - Fax:773-942-7166
Practice Address - Street 1:4941 N KEDZIE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-5009
Practice Address - Country:US
Practice Address - Phone:773-293-0451
Practice Address - Fax:773-942-7166
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-30
Last Update Date:2019-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL426180562085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL561510Medicare PIN