MEDICARE: NORTH SUBURBAN ULTRASOUND, LLC

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	261QR0208X	Mobile Radiology Clinic/Center		IL

General Provider Information

NPI Number	:	1801297288
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTH SUBURBAN ULTRASOUND, LLC

Provider Business Mailing Address
First Line	:	800 AUSTIN ST STE 466
Second Line	:
City	:	EVANSTON
State	:	IL
Zip	:	60202-3455
Country	:	US
Telephone Number	:	847-343-0205
Fax Number	:

Provider Business Practice Location Address
First Line	:	800 AUSTIN ST STE 466
Second Line	:
City	:	EVANSTON
State	:	IL
Zip	:	60202-3455
Country	:	US
Telephone Number	:	847-343-0205
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	BRADLEY A LAZAR
Credential	:
Telephone Number	:	847-343-0205

Provider Enumeration Date	:	09/04/2014
Last Update Date	:	04/16/2015

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