Healthcare Provider Details

I. General information

NPI: 1316309537
Provider Name (Legal Business Name): MICHAEL G NELLAMATTATHIL DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/26/2016
Last Update Date: 06/25/2026
Certification Date: 06/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2650 RIDGE AVE. DEPT. OF RADIOLOGY
EVANSTON IL
60201
US

IV. Provider business mailing address

2650 RIDGE AVE
EVANSTON IL
60201-1700
US

V. Phone/Fax

Practice location:
  • Phone: 847-570-2477
  • Fax: 847-570-2942
Mailing address:
  • Phone: 847-570-2477
  • Fax: 847-570-2942

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License Number036155190
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number036155190
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberOS23944
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: