Basic Information
| Provider Information | |||||||||
| NPI: | 1386200319 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ROUND LAKE MRI, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 720 E ROLLINS RD | ||||||||
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| City: | ROUND LAKE BEACH | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600731340 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8475463600 | ||||||||
| FaxNumber: | 8475463633 | ||||||||
| Practice Location | |||||||||
| Address1: | 720 E ROLLINS RD | ||||||||
| Address2: | |||||||||
| City: | ROUND LAKE BEACH | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600731340 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8475463600 | ||||||||
| FaxNumber: | 8475463633 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2019 | ||||||||
| LastUpdateDate: | 05/15/2019 | ||||||||
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| AuthorizedOfficialLastName: | THENGANATT | ||||||||
| AuthorizedOfficialFirstName: | JOSE | ||||||||
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| AuthorizedOfficialTitleorPosition: | TECHNICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8475463600 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ROUND LAKE MEDICAL IMAGING INC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | RT(R) | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Magnetic Resonance Imaging (MRI) |
No ID Information.