Healthcare Provider Details

I. General information

NPI: 1912199548
Provider Name (Legal Business Name): IMED GLENVIEW LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2007
Last Update Date: 08/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1247 MILWAUKEE AVE
GLENVIEW IL
60025-2464
US

IV. Provider business mailing address

1247 MILWAUKEE AVE
GLENVIEW IL
60025-2464
US

V. Phone/Fax

Practice location:
  • Phone: 847-962-3207
  • Fax: 847-835-3058
Mailing address:
  • Phone: 847-962-3207
  • Fax: 847-835-3058

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number StateIL

VIII. Authorized Official

Name: DR. ALEXANDER GORODETSKY
Title or Position: CO-OWNER
Credential: MD
Phone: 847-962-3207