Provider Demographics
NPI:1023178068
Name:MIDLICK'S MEDICAL IMAGING INC.
Entity type:Organization
Organization Name:MIDLICK'S MEDICAL IMAGING INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:GEORGE
Authorized Official - Last Name:MIDLICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-663-9811
Mailing Address - Street 1:6686 DOUBLE EAGLE DR
Mailing Address - Street 2:UNIT 103
Mailing Address - City:WOODRIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60517-5428
Mailing Address - Country:US
Mailing Address - Phone:630-663-9811
Mailing Address - Fax:630-663-9018
Practice Address - Street 1:6686 DOUBLE EAGLE DR
Practice Address - Street 2:UNIT 103
Practice Address - City:WOODRIDGE
Practice Address - State:IL
Practice Address - Zip Code:60517-5428
Practice Address - Country:US
Practice Address - Phone:630-663-9811
Practice Address - Fax:630-663-9018
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2017-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic UltrasoundGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL02230031OtherBLUE CROSS BLUE SHIELD
IL02230032OtherBLUE CROSS BLUE SHIELD
IL02230031OtherBLUE CROSS BLUE SHIELD
IL=========001Medicaid