Healthcare Provider Details

I. General information

NPI: 1033159090
Provider Name (Legal Business Name): MIDWAY DIAGNOSTIC CENTER LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2006
Last Update Date: 11/15/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5261 S CICERO AVE
CHICAGO IL
60632-4915
US

IV. Provider business mailing address

5261 S CICERO AVE
CHICAGO IL
60632-4915
US

V. Phone/Fax

Practice location:
  • Phone: 773-585-7508
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number
License Number StateIL

VIII. Authorized Official

Name: BOHDAN FEDIRKO
Title or Position: PRESIDENT
Credential:
Phone: 773-585-7505