Healthcare Provider Details

I. General information

NPI: 1881827251
Provider Name (Legal Business Name): ARCHER KEDZIE IMAGING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/01/2009
Last Update Date: 09/01/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4365 S ARCHER AVE
CHICAGO IL
60632-2826
US

IV. Provider business mailing address

4365 S ARCHER AVE
CHICAGO IL
60632-2826
US

V. Phone/Fax

Practice location:
  • Phone: 773-299-1070
  • Fax: 773-299-1075
Mailing address:
  • Phone: 773-299-1070
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1200X
TaxonomyMagnetic Resonance Imaging (MRI) Clinic/Center
License Number1964943
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number1964943
License Number StateIL

VIII. Authorized Official

Name: DR. MARVIN E. TAZELAAR
Title or Position: MANAGER
Credential:
Phone: 773-299-1070