Healthcare Provider Details

I. General information

NPI: 1851649974
Provider Name (Legal Business Name): EDGEBROOK OPEN MRI INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2012
Last Update Date: 08/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5320 W DEVON AVE
CHICAGO IL
60646-4108
US

IV. Provider business mailing address

5320 W DEVON AVE
CHICAGO IL
60646-4108
US

V. Phone/Fax

Practice location:
  • Phone: 773-774-6440
  • Fax: 773-774-4372
Mailing address:
  • Phone: 773-774-6440
  • Fax: 773-774-4372

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: TERRI NASSAR
Title or Position: MANAGER
Credential:
Phone: 708-481-9300