MEDICARE: METROPOLITAN DIAGNOSTIC 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	2085R0202X	Diagnostic Radiology Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	21621866	OTHER	IL	BLUE CROSS BLUE SHEILD

General Provider Information

NPI Number	:	1669483988
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	METROPOLITAN DIAGNOSTIC IMAGING

Provider Business Mailing Address
First Line	:	111 N WABASH AVE
Second Line	:	SUITE 620
City	:	CHICAGO
State	:	IL
Zip	:	60602-1903
Country	:	US
Telephone Number	:	312-807-3555
Fax Number	:	312-807-3922

Provider Business Practice Location Address
First Line	:	1332 E 47TH ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60653-4508
Country	:	US
Telephone Number	:	773-624-5400
Fax Number	:	773-624-5408

Authorized Official
Title or Position	:	PRESIDENT/MEDICAL DIRECTOR
Name	:	JOEL LELAND
Credential	:	DO
Telephone Number	:	312-807-3555

Provider Enumeration Date	:	08/11/2006
Last Update Date	:	08/22/2020

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