MEDICARE: LINCOLN PARK OPEN MRI, LLC

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	2085R0202X	Diagnostic Radiology Physician

General Provider Information

NPI Number	:	1326165465
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LINCOLN PARK OPEN MRI, LLC

Provider Business Mailing Address
First Line	:	7200 N WESTERN AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60645-1812
Country	:	US
Telephone Number	:	773-761-0200
Fax Number	:	773-761-0202

Provider Business Practice Location Address
First Line	:	812 W CHICAGO AVE
Second Line	:
City	:	EAST CHICAGO
State	:	IN
Zip	:	46312-3307
Country	:	US
Telephone Number	:	219-392-8888
Fax Number	:	219-392-8812

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. RAGHU NAYAK
Credential	:
Telephone Number	:	219-392-8888

Provider Enumeration Date	:	03/23/2007
Last Update Date	:	08/22/2020

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