Provider Demographics
NPI:1639341662
Name:UNITED IMAGING & DIAGNOSTICS
Entity Type:Organization
Organization Name:UNITED IMAGING & DIAGNOSTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BOGDAN
Authorized Official - Middle Name:
Authorized Official - Last Name:LYSENKO
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:847-778-4825
Mailing Address - Street 1:1600 W DEMPSTER ST
Mailing Address - Street 2:SUITE 206
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068-1109
Mailing Address - Country:US
Mailing Address - Phone:847-299-3434
Mailing Address - Fax:847-299-3495
Practice Address - Street 1:1600 W DEMPSTER ST
Practice Address - Street 2:SUITE 206
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-1109
Practice Address - Country:US
Practice Address - Phone:847-299-3434
Practice Address - Fax:847-299-3495
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-31
Last Update Date:2009-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL 1429Medicare PIN