Provider Demographics
NPI:1063218535
Name:WOOD DALE RADIOLOGY LLC
Entity type:Organization
Organization Name:WOOD DALE RADIOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:NELLAMATTATHIL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-329-8030
Mailing Address - Street 1:PO BOX 7389
Mailing Address - Street 2:
Mailing Address - City:PROSPECT HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60070-7389
Mailing Address - Country:US
Mailing Address - Phone:847-870-3600
Mailing Address - Fax:847-870-3500
Practice Address - Street 1:199 S ADDISON RD STE 107B
Practice Address - Street 2:
Practice Address - City:WOOD DALE
Practice Address - State:IL
Practice Address - Zip Code:60191-1978
Practice Address - Country:US
Practice Address - Phone:630-329-8030
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-02-24
Last Update Date:2025-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty