Healthcare Provider Details

I. General information

NPI: 1922456474
Provider Name (Legal Business Name): BERWYN IMAGING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2016
Last Update Date: 10/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6728 CERMAK RD
BERWYN IL
60402-2217
US

IV. Provider business mailing address

6728 CERMAK RD
BERWYN IL
60402-2217
US

V. Phone/Fax

Practice location:
  • Phone: 708-788-8900
  • Fax: 708-788-5110
Mailing address:
  • Phone: 708-788-8900
  • Fax: 708-788-5110

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1200X
TaxonomyMagnetic Resonance Imaging (MRI) Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MARVIN TAZELAAR
Title or Position: DIRECTOR
Credential:
Phone: 630-333-4674