Healthcare Provider Details

I. General information

NPI: 1356310163
Provider Name (Legal Business Name): NORTHWEST SUBURBAN IMAGING ASSOCIATES, S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2006
Last Update Date: 06/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1425 N RANDALL RD
ELGIN IL
60123-2300
US

IV. Provider business mailing address

34659 EAGLE WAY
CHICAGO IL
60678-1346
US

V. Phone/Fax

Practice location:
  • Phone: 847-742-9800
  • Fax:
Mailing address:
  • Phone: 630-874-2542
  • Fax: 630-874-2642

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085N0904X
TaxonomyNuclear Radiology Physician
License Number036062431
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number036062431
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code207U00000X
TaxonomyNuclear Medicine Physician
License Number036062431
License Number StateIL
# 4
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number036062431
License Number StateIL

VIII. Authorized Official

Name: AJAY MEHTA
Title or Position: PRESIDENT
Credential: M.D.
Phone: 847-742-9800