Healthcare Provider Details

I. General information

NPI: 1265765218
Provider Name (Legal Business Name): 4365 ARCHER MRI, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2009
Last Update Date: 09/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4365 SOUTH ARCHER AVENUE
CHICAGO IL
60632
US

IV. Provider business mailing address

PO BOX 7389
PROSPECT HEIGHTS IL
60070-7389
US

V. Phone/Fax

Practice location:
  • Phone: 773-299-1071
  • Fax: 773-299-1074
Mailing address:
  • Phone: 847-870-3600
  • Fax: 847-370-3500

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number1959633
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code261QM1200X
TaxonomyMagnetic Resonance Imaging (MRI) Clinic/Center
License Number1959633
License Number StateIL

VIII. Authorized Official

Name: DR. MARVIN E. TAZELAAR
Title or Position: MANAGER
Credential:
Phone: 773-299-1071