MEDICARE: CHICAGO MAXILLOFACIAL IMAGING

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	2471C3401X	Computed Tomography Radiologic Technologist

General Provider Information

NPI Number	:	1386818466
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHICAGO MAXILLOFACIAL IMAGING

Provider Business Mailing Address
First Line	:	2449 N LINCOLN AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60614-2414
Country	:	US
Telephone Number	:	773-327-2400
Fax Number	:	773-327-4759

Provider Business Practice Location Address
First Line	:	2449 N LINCOLN AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60614-2414
Country	:	US
Telephone Number	:	773-327-2400
Fax Number	:	773-327-4759

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MRS. LIZBETH CANALES
Credential	:
Telephone Number	:	773-327-2400

Provider Enumeration Date	:	04/18/2008
Last Update Date	:	04/18/2008

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Directions to “CHICAGO MAXILLOFACIAL IMAGING ” Practice Location

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