Provider Demographics
NPI:1720539646
Name:BERWYN DIAGNOSTIC IMAGING LLC
Entity Type:Organization
Organization Name:BERWYN DIAGNOSTIC IMAGING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:M
Authorized Official - Last Name:COAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-788-8900
Mailing Address - Street 1:6728 CERMAK RD
Mailing Address - Street 2:
Mailing Address - City:BERWYN
Mailing Address - State:IL
Mailing Address - Zip Code:60402-2217
Mailing Address - Country:US
Mailing Address - Phone:708-788-8900
Mailing Address - Fax:
Practice Address - Street 1:6728 CERMAK RD
Practice Address - Street 2:
Practice Address - City:BERWYN
Practice Address - State:IL
Practice Address - Zip Code:60402-2217
Practice Address - Country:US
Practice Address - Phone:708-788-8900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-14
Last Update Date:2016-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)
No261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology