Healthcare Provider Details

I. General information

NPI: 1144494584
Provider Name (Legal Business Name): WAYDE HITOSHI NAGAMINE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2008
Last Update Date: 06/10/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3249 OAK PARK AVE METROPOLITAN ADVANCED RADIOLOGICAL SERVICES
BERWYN IL
60402-3429
US

IV. Provider business mailing address

3249 OAK PARK AVE METROPOLITAN ADVANCED RADIOLOGICAL SERVICES
BERWYN IL
60402-3429
US

V. Phone/Fax

Practice location:
  • Phone: 708-783-2696
  • Fax: 708-783-3164
Mailing address:
  • Phone: 708-783-2696
  • Fax: 708-783-3164

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number036-116127
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number093376
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number13005
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: