Basic Information
| Provider Information | |||||||||
| NPI: | 1528013422 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ILLINI MRI LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 801 ILLINI DR | ||||||||
| Address2: | |||||||||
| City: | SILVIS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 612821804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3097929363 | ||||||||
| FaxNumber: | 5634213419 | ||||||||
| Practice Location | |||||||||
| Address1: | 801 ILLINI DR | ||||||||
| Address2: | |||||||||
| City: | SILVIS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 612821804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3097929363 | ||||||||
| FaxNumber: | 5634213419 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | BRUHN | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3097924265 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0200X | IL | Y | Ambulatory Health Care Facilities | Clinic/Center | Radiology |
ID Information
| ID | Type | State | Issuer | Description | 634002 | 01 | HEALTHLINK | OTHER | 0813286 | 01 | IL | BLUE CROSS ILLINOIS | OTHER | IL0100 | 01 | IL | JOHN DEERE HEALTHCARE | OTHER | 90359 | 01 | IA | IOWA BLUE CROSS | OTHER |