MEDICARE: ELK GROVE MRI INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM1200X	Magnetic Resonance Imaging (MRI) Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	31623087	OTHER	IL	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1043245285
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ELK GROVE MRI INC.

Provider Business Mailing Address
First Line	:	901 BIESTERFIELD RD STE 110
Second Line	:
City	:	ELK GROVE VILLAGE
State	:	IL
Zip	:	60007-3393
Country	:	US
Telephone Number	:	847-357-9300
Fax Number	:	847-357-0800

Provider Business Practice Location Address
First Line	:	901 BIESTERFIELD RD STE 110
Second Line	:
City	:	ELK GROVE VILLAGE
State	:	IL
Zip	:	60007-3393
Country	:	US
Telephone Number	:	847-357-9300
Fax Number	:	847-357-0800

Authorized Official
Title or Position	:	BILLING MANAGER
Name	:	LILLIAN IRIS YUQUILIMA
Credential	:
Telephone Number	:	847-357-9300

Provider Enumeration Date	:	07/12/2006
Last Update Date	:	09/25/2008

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