MEDICARE: ATHENOS MEDICAL DIAGNOSTICS, LTD

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number State
1	111N00000X	Chiropractor	IL
2	207R00000X	Internal Medicine Physician	IL
3	2084D0003X	Diagnostic Neuroimaging (Psychiatry & Neurology) Physician	IL
4	208VP0014X	Interventional Pain Medicine Physician	IL

General Provider Information

NPI Number	:	1386812444
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ATHENOS MEDICAL DIAGNOSTICS, LTD

Provider Business Mailing Address
First Line	:	5445 N SHERIDAN RD
Second Line	:	SUITE 512
City	:	CHICAGO
State	:	IL
Zip	:	60640-1957
Country	:	US
Telephone Number	:	312-804-8910
Fax Number	:	630-969-4528

Provider Business Practice Location Address
First Line	:	5445 N SHERIDAN RD
Second Line	:	SUITE 512
City	:	CHICAGO
State	:	IL
Zip	:	60640-1957
Country	:	US
Telephone Number	:	312-804-8910
Fax Number	:	630-969-4528

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. DREW S KANDILAKIS
Credential	:	D.C.
Telephone Number	:	312-804-8910

Provider Enumeration Date	:	02/12/2008
Last Update Date	:	02/12/2008

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