Provider Demographics
NPI:1902896277
Name:GLEN MEDICAL IMAGING, INC.
Entity Type:Organization
Organization Name:GLEN MEDICAL IMAGING, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ALEX
Authorized Official - Middle Name:
Authorized Official - Last Name:AKSELRUD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-215-9840
Mailing Address - Street 1:251 MILWAUKEE AVE
Mailing Address - Street 2:SUITE 1016
Mailing Address - City:BUFFFALO GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60089-2826
Mailing Address - Country:US
Mailing Address - Phone:847-215-9840
Mailing Address - Fax:847-215-9843
Practice Address - Street 1:251 MILWAUKEE AVE
Practice Address - Street 2:SUITE 1016
Practice Address - City:BUFFALO GROVE
Practice Address - State:IL
Practice Address - Zip Code:60089-2809
Practice Address - Country:US
Practice Address - Phone:847-215-9840
Practice Address - Fax:847-215-9843
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-26
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes293D00000XLaboratoriesPhysiological Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL208189Medicare ID - Type Unspecified
IL208214Medicare ID - Type Unspecified