MEDICARE: MIDWEST DIAGNOSTIC 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	261QM1300X	Multi-Specialty Clinic/Center

General Provider Information

NPI Number	:	1740234384
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIDWEST DIAGNOSTIC INC.

Provider Business Mailing Address
First Line	:	2600 W PETERSON AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60659-4098
Country	:	US
Telephone Number	:	773-944-5775
Fax Number	:	773-944-9779

Provider Business Practice Location Address
First Line	:	2600 W PETERSON AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60659-4098
Country	:	US
Telephone Number	:	773-944-5775
Fax Number	:	773-944-9779

Authorized Official
Title or Position	:	PRESIDENT/ADMINISTRATOR
Name	:	SYED RIAZUL HASSAN
Credential	:
Telephone Number	:	773-392-6888

Provider Enumeration Date	:	05/19/2006
Last Update Date	:	08/22/2020

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