Provider Demographics
NPI:1669430690
Name:MDS-MOBILE DIAGNOSTIC SERVICES, INC
Entity type:Organization
Organization Name:MDS-MOBILE DIAGNOSTIC SERVICES, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:FAITH
Authorized Official - Middle Name:A
Authorized Official - Last Name:CAMPBELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-378-4588
Mailing Address - Street 1:8770 W BRYN MAWR AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60631-3515
Mailing Address - Country:US
Mailing Address - Phone:773-253-4963
Mailing Address - Fax:
Practice Address - Street 1:8770 W BRYN MAWR AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60631-3515
Practice Address - Country:US
Practice Address - Phone:773-253-4963
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-01
Last Update Date:2009-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335V00000XSuppliersPortable X-ray and/or Other Portable Diagnostic Imaging Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001MedicaidIL MEDICAID PROVIDER NUMB
IL=========001Medicaid
IL=========001Medicaid