MEDICARE: DIVISION MRI, 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	293D00000X	Physiological Laboratory

General Provider Information

NPI Number	:	1780826230
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIVISION MRI, INC.

Provider Business Mailing Address
First Line	:	PO BOX 220450
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60622-0450
Country	:	US
Telephone Number	:	773-235-7455
Fax Number	:	773-235-7055

Provider Business Practice Location Address
First Line	:	2618 W DIVISION ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60622-7107
Country	:	US
Telephone Number	:	773-235-7455
Fax Number	:	773-235-7055

Authorized Official
Title or Position	:	OWNER/PRESIDENT
Name	:	DR. AMER RUSTUM
Credential	:	MD
Telephone Number	:	773-456-3384

Provider Enumeration Date	:	03/30/2009
Last Update Date	:	01/07/2010

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