MEDICARE: MAYFAIR ADVANTAGE 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	261QM1200X	Magnetic Resonance Imaging (MRI) Clinic/Center

General Provider Information

NPI Number	:	1982014064
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MAYFAIR ADVANTAGE MRI, INC

Provider Business Mailing Address
First Line	:	4351 N CICERO AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60641-1502
Country	:	US
Telephone Number	:	773-427-1222
Fax Number	:	773-427-1333

Provider Business Practice Location Address
First Line	:	4351 N CICERO AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60641-1502
Country	:	US
Telephone Number	:	773-427-1222
Fax Number	:	773-427-1333

Authorized Official
Title or Position	:	MANAGER
Name	:	MR. GEORGE T NELLAMATTATHIL
Credential	:	RT(R) (CT)(MR)
Telephone Number	:	847-533-9029

Provider Enumeration Date	:	04/29/2014
Last Update Date	:	04/29/2014

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