MEDICARE: GLEN MEDICAL IMAGING, 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	:	1902896277
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GLEN MEDICAL IMAGING, INC.

Provider Business Mailing Address
First Line	:	251 MILWAUKEE AVE
Second Line	:	SUITE 1016
City	:	BUFFFALO GROVE
State	:	IL
Zip	:	60089-2826
Country	:	US
Telephone Number	:	847-215-9840
Fax Number	:	847-215-9843

Provider Business Practice Location Address
First Line	:	251 MILWAUKEE AVE
Second Line	:	SUITE 1016
City	:	BUFFALO GROVE
State	:	IL
Zip	:	60089-2809
Country	:	US
Telephone Number	:	847-215-9840
Fax Number	:	847-215-9843

Authorized Official
Title or Position	:	OWNER/PRESIDENT
Name	:	MR. ALEX AKSELRUD
Credential	:
Telephone Number	:	847-215-9840

Provider Enumeration Date	:	10/26/2005
Last Update Date	:	04/20/2008

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