Provider Demographics
NPI:1629158605
Name:IDEAL HEALTH DIAGNOSTICS, INC.
Entity Type:Organization
Organization Name:IDEAL HEALTH DIAGNOSTICS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SVETLANA
Authorized Official - Middle Name:
Authorized Official - Last Name:DIZIK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-293-7704
Mailing Address - Street 1:145 W DUNDEE RD
Mailing Address - Street 2:
Mailing Address - City:BUFFALO GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60089-3706
Mailing Address - Country:US
Mailing Address - Phone:847-293-7704
Mailing Address - Fax:
Practice Address - Street 1:145 W DUNDEE RD
Practice Address - Street 2:
Practice Address - City:BUFFALO GROVE
Practice Address - State:IL
Practice Address - Zip Code:60089-3706
Practice Address - Country:US
Practice Address - Phone:847-293-7704
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL626700OtherGROUP PIN #
IL01629955OtherBCBS PROVIDER NUMBER
IL01629955OtherBCBS PROVIDER NUMBER
IL626700Medicare ID - Type Unspecified
IL=========Medicaid