Healthcare Provider Details

I. General information

NPI: 1023444890
Provider Name (Legal Business Name): BUCKTOWN OPEN MRI, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/24/2013
Last Update Date: 09/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1717 N ASHLAND AVE
CHICAGO IL
60622-1449
US

IV. Provider business mailing address

1717 N ASHLAND AVE
CHICAGO IL
60622-1449
US

V. Phone/Fax

Practice location:
  • Phone: 773-772-9988
  • Fax: 773-772-9989
Mailing address:
  • Phone: 773-772-9988
  • Fax: 773-772-9989

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: MR. EDWIN SAGE
Title or Position: MEMBER MANAGER
Credential:
Phone: 773-772-9988