MEDICARE: MIDWAY DIAGNOSTIC CENTER LTD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	173000000X	Legal Medicine		IL

General Provider Information

NPI Number	:	1033159090
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIDWAY DIAGNOSTIC CENTER LTD

Provider Business Mailing Address
First Line	:	5261 S CICERO AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60632-4915
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5261 S CICERO AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60632-4915
Country	:	US
Telephone Number	:	773-585-7508
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	BOHDAN FEDIRKO
Credential	:
Telephone Number	:	773-585-7505

Provider Enumeration Date	:	06/07/2006
Last Update Date	:	11/15/2007

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