Healthcare Provider Details

I. General information

NPI: 1568419778
Provider Name (Legal Business Name): MEDIQUEST DIAGNOSTIC CENTER S.C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2006
Last Update Date: 11/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3420 W PETERSON AVE
CHICAGO IL
60659-3418
US

IV. Provider business mailing address

3420 W PETERSON AVE
CHICAGO IL
60659-3418
US

V. Phone/Fax

Practice location:
  • Phone: 773-604-4305
  • Fax: 847-296-8860
Mailing address:
  • Phone: 773-604-4305
  • Fax: 847-296-8860

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2471C3402X
TaxonomyRadiography Radiologic Technologist
License Number9258142
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code246XS1301X
TaxonomySonography Specialist/Technologist Cardiovascular
License NumberN / A
License Number StateIL

VIII. Authorized Official

Name: MRS. SABIHA N AHMED
Title or Position: PRESIDENT
Credential: B.S
Phone: 630-894-6105