MEDICARE: MDS-MOBILE DIAGNOSTIC SERVICES, INC

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	335V00000X	Portable X-ray and/or Other Portable Diagnostic Imaging Supplier

General Provider Information

NPI Number	:	1669430690
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MDS-MOBILE DIAGNOSTIC SERVICES, INC

Provider Business Mailing Address
First Line	:	8770 W BRYN MAWR AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60631-3515
Country	:	US
Telephone Number	:	773-253-4963
Fax Number	:

Provider Business Practice Location Address
First Line	:	8770 W BRYN MAWR AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60631-3515
Country	:	US
Telephone Number	:	773-253-4963
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MRS. FAITH A CAMPBELL
Credential	:
Telephone Number	:	217-378-4588

Provider Enumeration Date	:	05/01/2006
Last Update Date	:	03/25/2009

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