MEDICARE: CHICAGO NORTHSIDE HOSPITAL MRI

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	174400000X	Specialist		IL
2	293D00000X	Physiological Laboratory

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1618295	OTHER	IL	BCBS IL PROVIDER NUMBER

General Provider Information

NPI Number	:	1902956923
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHICAGO NORTHSIDE HOSPITAL MRI

Provider Business Mailing Address
First Line	:	29373 NETWORK PL
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60673-1293
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1460 N HALSTED ST
Second Line	:	SUITE 102
City	:	CHICAGO
State	:	IL
Zip	:	60642-2605
Country	:	US
Telephone Number	:	773-525-2818
Fax Number	:	773-525-8589

Authorized Official
Title or Position	:	VP MANAGED HEALTH
Name	:	MRS. KARA RICHARDSON
Credential	:
Telephone Number	:	980-416-4068

Provider Enumeration Date	:	01/11/2007
Last Update Date	:	06/01/2026

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