Provider Demographics
NPI:1821045659
Name:EDGEBROOK RADIOLOGY MANAGEMENT
Entity Type:Organization
Organization Name:EDGEBROOK RADIOLOGY MANAGEMENT
Other - Org Name:EDGEBROOK RADIOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:NELLAMATHATIL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-774-6440
Mailing Address - Street 1:PO BOX 7389
Mailing Address - Street 2:
Mailing Address - City:PROSPECT HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60070-7389
Mailing Address - Country:US
Mailing Address - Phone:847-870-3600
Mailing Address - Fax:847-870-3500
Practice Address - Street 1:5320 W DEVON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60646-4108
Practice Address - Country:US
Practice Address - Phone:773-774-6440
Practice Address - Fax:773-774-4372
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-27
Last Update Date:2009-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL261QM1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL701780Medicare ID - Type Unspecified