=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396744751
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTHERN ILLINOIS DIAGNOSTIC MEDICAL IMAGING
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/19/2005
-----------------------------------------------------
Last Update Date | 02/09/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 200 BERTEAU AVE
-----------------------------------------------------
City | ELMHURST
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60126-2966
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-833-1400
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 520 E 22ND ST
-----------------------------------------------------
City | LOMBARD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60148-6110
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-874-2542
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHAIRMAN
-----------------------------------------------------
Name | ROBERT L PEISS
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 630-833-1400
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085N0904X
-----------------------------------------------------
Taxonomy Name | Nuclear Radiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------