MEDICARE: DIVISION MEDICAL & DIAGNOSTICS INC

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	2471S1302X	Sonography Radiologic Technologist		IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1625675	OTHER	IL	BLUE SHIELD OF IL

General Provider Information

NPI Number	:	1013012681
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIVISION MEDICAL & DIAGNOSTICS INC

Provider Business Mailing Address
First Line	:	4913 W FULLERTON AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60639-2505
Country	:	US
Telephone Number	:	773-637-2000
Fax Number	:	773-367-2006

Provider Business Practice Location Address
First Line	:	4913 W FULLERTON AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60639-2505
Country	:	US
Telephone Number	:	773-637-2000
Fax Number	:	773-367-2006

Authorized Official
Title or Position	:	PRESIDENT
Name	:	RAGHU NAYAK
Credential	:
Telephone Number	:	630-986-1240

Provider Enumeration Date	:	09/14/2006
Last Update Date	:	08/22/2020

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