Basic Information
| Provider Information | |||||||||
| NPI: | 1902824915 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | IWANIK | ||||||||
| FirstName: | DIANA | ||||||||
| MiddleName: | O. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7435 W. TALCOTT AVENUE | ||||||||
| Address2: | PRESENCE RMC, RADIOLOGY DEPARTMENT | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606313745 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7739907684 | ||||||||
| FaxNumber: | 7737925124 | ||||||||
| Practice Location | |||||||||
| Address1: | 7435 W. TALCOTT AVENUE | ||||||||
| Address2: | PRESENCE RMC, RADIOLOGY DEPARTMENT | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606313745 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7739907684 | ||||||||
| FaxNumber: | 7737925124 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2006 | ||||||||
| LastUpdateDate: | 03/31/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/31/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085U0001X | 036072868 | IL | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Ultrasound | 2085R0202X | 036072868 | IL | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085B0100X | 036072868 | IL | N | Allopathic & Osteopathic Physicians | Radiology | Body Imaging | 2085N0700X | 036072868 | IL | N | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology | 2085N0904X | 036072868 | IL | N | Allopathic & Osteopathic Physicians | Radiology | Nuclear Radiology | 2085P0229X | 036072868 | IL | N | Allopathic & Osteopathic Physicians | Radiology | Pediatric Radiology |
ID Information
| ID | Type | State | Issuer | Description | 036072868-2 | 05 | IL | MEDICAID | 0001619902 | 01 | IL | BLUE CROSS BLUE SHIELD-IL | OTHER | 036072868 | 05 | IL | MEDICAID |