Healthcare Provider Details

I. General information

NPI: 1558600106
Provider Name (Legal Business Name): MINIMALLY INVASIVE THERAPY SPECIALISTS SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2013
Last Update Date: 10/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5011 N LINCOLN AVE
CHICAGO IL
60625-6351
US

IV. Provider business mailing address

5011 N LINCOLN AVE
CHICAGO IL
60625-6351
US

V. Phone/Fax

Practice location:
  • Phone: 844-646-8763
  • Fax: 855-497-2932
Mailing address:
  • Phone: 844-646-8763
  • Fax: 855-497-2932

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. IFTIKHAR AHMAD
Title or Position: PRESIDENT AND CEO
Credential: MD
Phone: 844-646-8763