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General NPI Number Information
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NPI Number | 1912199548
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Entity Type | Organization
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Legal Business Name | IMED GLENVIEW LLC
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Dates
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Enumeration Date | 08/16/2007
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Last Update Date | 08/16/2007
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Provider Practice Location Address
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Address Line | 1247 MILWAUKEE AVE
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City | GLENVIEW
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State | IL
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Zip | 60025-2464
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Country | US
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Telephone | 847-962-3207
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Fax | 847-835-3058
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Provider Business Mailing Address
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Address Line | 1247 MILWAUKEE AVE
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City | GLENVIEW
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State | IL
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Zip | 60025-2464
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Country | US
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Telephone | 847-962-3207
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Fax | 847-835-3058
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Authorized Official
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Title or Position | CO-OWNER
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Name | DR. ALEXANDER GORODETSKY
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Credential | MD
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Telephone | 847-962-3207
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number |
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State | IL
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