Provider Demographics
NPI:1669483988
Name:METROPOLITAN DIAGNOSTIC IMAGING
Entity Type:Organization
Organization Name:METROPOLITAN DIAGNOSTIC IMAGING
Other - Org Name:AMIC HYDE PARK OPEN MRI
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT/MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOEL
Authorized Official - Middle Name:
Authorized Official - Last Name:LELAND
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:312-807-3555
Mailing Address - Street 1:111 N WABASH AVE
Mailing Address - Street 2:SUITE 620
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60602-1903
Mailing Address - Country:US
Mailing Address - Phone:312-807-3555
Mailing Address - Fax:312-807-3922
Practice Address - Street 1:1332 E 47TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60653-4508
Practice Address - Country:US
Practice Address - Phone:773-624-5400
Practice Address - Fax:773-624-5408
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL21621866OtherBLUE CROSS BLUE SHEILD
IL=========002Medicaid
IL=========002Medicaid