Basic Information
| Provider Information | |||||||||
| NPI: | 1194710905 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OPEN MRI OF SOUTHERN ILLINOIS LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | IMAGING CENTER OF SOUTHERN ILLINOIS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 868 | ||||||||
| Address2: | |||||||||
| City: | EDWARDSVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620250868 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6186591167 | ||||||||
| FaxNumber: | 6186591197 | ||||||||
| Practice Location | |||||||||
| Address1: | 2016 VADALABENE DR | ||||||||
| Address2: | |||||||||
| City: | MARYVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620626901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182884929 | ||||||||
| FaxNumber: | 6182884531 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/19/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | MCRAE | ||||||||
| AuthorizedOfficialFirstName: | STEVEN | ||||||||
| AuthorizedOfficialMiddleName: | MICHAEL | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 6186591167 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Radiology |
No ID Information.