Healthcare Provider Details

I. General information

NPI: 1609139419
Provider Name (Legal Business Name): MIDWEST IMAGING PROFESSIONALS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2012
Last Update Date: 07/12/2024
Certification Date: 07/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2233 W DIVISION ST
CHICAGO IL
60622-8151
US

IV. Provider business mailing address

PO BOX 208949
DALLAS TX
75320-8949
US

V. Phone/Fax

Practice location:
  • Phone: 312-770-2000
  • Fax: 630-571-8810
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: SHARLEE LEBLEU JR.
Title or Position: VICE PRESIDENT
Credential:
Phone: 480-321-7026