MEDICARE: PROFESSIONAL DIAGNOSTIC SERVICE, S.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency	A-3920-0003-A	IL

General Provider Information

NPI Number	:	1003063421
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROFESSIONAL DIAGNOSTIC SERVICE, S.C.

Provider Business Mailing Address
First Line	:	821 W VAN BUREN ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60607-3517
Country	:	US
Telephone Number	:	312-491-0404
Fax Number	:	312-491-0505

Provider Business Practice Location Address
First Line	:	821 W VAN BUREN ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60607-3517
Country	:	US
Telephone Number	:	312-491-0404
Fax Number	:	312-491-0505

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. KENNETH DAVIS
Credential	:	PH.D./MD
Telephone Number	:	312-491-0404

Provider Enumeration Date	:	08/27/2008
Last Update Date	:	08/27/2008

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