Basic Information
| Provider Information | |||||||||
| NPI: | 1700838562 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SCHWARTZ | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | P | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1121 LAKE COOK RD | ||||||||
| Address2: | STE M | ||||||||
| City: | DEERFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600155234 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8479454550 | ||||||||
| FaxNumber: | 8479488103 | ||||||||
| Practice Location | |||||||||
| Address1: | 1416C S RANDALL RD | ||||||||
| Address2: | RANDALL SQUAR SHOPPING CENTER | ||||||||
| City: | GENEVA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601344682 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6302089325 | ||||||||
| FaxNumber: | 6302089326 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2006 | ||||||||
| LastUpdateDate: | 09/16/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085N0904X | 036042528 | IL | N | Allopathic & Osteopathic Physicians | Radiology | Nuclear Radiology | 2085R0202X | 036042528 | IL | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 036042528 | 05 | IL | MEDICAID |