MEDICARE: CHICAGO RIDGE RADIOLOGY SC

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	261QM1300X	Multi-Specialty Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1548282114
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHICAGO RIDGE RADIOLOGY SC

Provider Business Mailing Address
First Line	:	2448 S 102ND ST
Second Line	:	STE 125
City	:	WEST ALLIS
State	:	WI
Zip	:	53227-2466
Country	:	US
Telephone Number	:	414-328-3800
Fax Number	:	414-328-3818

Provider Business Practice Location Address
First Line	:	9830 RIDGELAND AVE
Second Line	:	STE #4
City	:	CHICAGO RIDGE
State	:	IL
Zip	:	60415-2667
Country	:	US
Telephone Number	:	708-423-1819
Fax Number	:	708-423-4788

Authorized Official
Title or Position	:	VICE PRESIDENT
Name	:	ABDUL AMINE
Credential	:	M.D.
Telephone Number	:	708-430-3350

Provider Enumeration Date	:	07/24/2006
Last Update Date	:	04/01/2010

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