Basic Information
| Provider Information | |||||||||
| NPI: | 1093770851 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OPEN ADVANCED MRI OF CRYSTAL LAKE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 820 E TERRA COTTA AVE | ||||||||
| Address2: | SUITE 136 | ||||||||
| City: | CRYSTAL LAKE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600143649 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8154441330 | ||||||||
| FaxNumber: | 8154441279 | ||||||||
| Practice Location | |||||||||
| Address1: | 820 E TERRA COTTA AVE | ||||||||
| Address2: | SUITE 136 | ||||||||
| City: | CRYSTAL LAKE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600143649 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8154441330 | ||||||||
| FaxNumber: | 8154441279 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | HOULIHAN | ||||||||
| AuthorizedOfficialFirstName: | MARY | ||||||||
| AuthorizedOfficialMiddleName: | PAT | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8154441330 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | CK3870 | 01 | IL | RAILROAD MEDICARE | OTHER | 05630041 | 01 | IL | BLUE SHIELD | OTHER |