=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033513262
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DHK RADIOLOGY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/17/2014
-----------------------------------------------------
Last Update Date | 10/17/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 55 E ERIE ST APT 2203
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60611-2798
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-691-7673
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 55 E ERIE ST APT 2203
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60611-2798
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JAY KORACH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 847-691-7673
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number | 1062709
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------