MEDICARE: SAUK VALLEY OPEN MRI, LLC

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		IL

General Provider Information

NPI Number	:	1659376523
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SAUK VALLEY OPEN MRI, LLC

Provider Business Mailing Address
First Line	:	1622 SAUK RD
Second Line	:
City	:	DIXON
State	:	IL
Zip	:	61021-8777
Country	:	US
Telephone Number	:	815-284-4674
Fax Number	:	815-284-4691

Provider Business Practice Location Address
First Line	:	1622 SAUK RD
Second Line	:
City	:	DIXON
State	:	IL
Zip	:	61021-8777
Country	:	US
Telephone Number	:	815-284-4674
Fax Number	:	815-284-4691

Authorized Official
Title or Position	:	MANAGER
Name	:	MR. STEVEN A. METCALF
Credential	:	MBA
Telephone Number	:	815-284-4674

Provider Enumeration Date	:	06/16/2005
Last Update Date	:	08/22/2020

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