Healthcare Provider Details

I. General information

NPI: 1225563380
Provider Name (Legal Business Name): ROUND LAKE MEDICAL IMAGING INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2017
Last Update Date: 04/26/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 E ROLLINS RD
ROUND LAKE BEACH IL
60073-1340
US

IV. Provider business mailing address

720 E ROLLINS RD
ROUND LAKE BEACH IL
60073-1340
US

V. Phone/Fax

Practice location:
  • Phone: 847-546-3600
  • Fax:
Mailing address:
  • Phone: 847-546-3600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1200X
TaxonomyMagnetic Resonance Imaging (MRI) Clinic/Center
License Number500505334
License Number StateIL

VIII. Authorized Official

Name: MR. JOSE THENGANATT
Title or Position: DIRECTOR
Credential:
Phone: 847-922-6306