Healthcare Provider Details

I. General information

NPI: 1902824915
Provider Name (Legal Business Name): DIANA O. IWANIK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 03/31/2021
Certification Date: 03/31/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7435 W. TALCOTT AVENUE PRESENCE RMC, RADIOLOGY DEPARTMENT
CHICAGO IL
60631-3745
US

IV. Provider business mailing address

7435 W. TALCOTT AVENUE PRESENCE RMC, RADIOLOGY DEPARTMENT
CHICAGO IL
60631-3745
US

V. Phone/Fax

Practice location:
  • Phone: 773-990-7684
  • Fax: 773-792-5124
Mailing address:
  • Phone: 773-990-7684
  • Fax: 773-792-5124

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085U0001X
TaxonomyDiagnostic Ultrasound Physician
License Number036072868
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number036072868
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License Number036072868
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number036072868
License Number StateIL
# 5
Primary TaxonomyN
Taxonomy Code2085N0904X
TaxonomyNuclear Radiology Physician
License Number036072868
License Number StateIL
# 6
Primary TaxonomyN
Taxonomy Code2085P0229X
TaxonomyPediatric Radiology Physician
License Number036072868
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: