Basic Information
| Provider Information | |||||||||
| NPI: | 1164475737 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DIAGNOSTIC NEUROLOGY, LTD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 388320 | ||||||||
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| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606388320 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7737678283 | ||||||||
| FaxNumber: | 7737678320 | ||||||||
| Practice Location | |||||||||
| Address1: | 444 N NORTHWEST HWY | ||||||||
| Address2: | STE 200 | ||||||||
| City: | PARK RIDGE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600683263 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8478252366 | ||||||||
| FaxNumber: | 8478252513 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | KOVELESKI | ||||||||
| AuthorizedOfficialFirstName: | JULES | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8478252366 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 01615936 | 01 | IL | BLUE SHIELD | OTHER |