Healthcare Provider Details

I. General information

NPI: 1891750337
Provider Name (Legal Business Name): BERWYN MAGNETIC RESONANCE CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2006
Last Update Date: 11/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3345 OAK PARK AVE
BERWYN IL
60402-3434
US

IV. Provider business mailing address

PO BOX 404166
ATLANTA GA
30384-4166
US

V. Phone/Fax

Practice location:
  • Phone: 708-788-9400
  • Fax: 708-788-6369
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code293D00000X
TaxonomyPhysiological Laboratory
License Number
License Number State

VIII. Authorized Official

Name: MR. BRIAN G DRAZBA
Title or Position: SENIOR V.P. & CHIEF ACCOUNTING OFCR
Credential:
Phone: 949-282-6000