Healthcare Provider Details

I. General information

NPI: 1003809674
Provider Name (Legal Business Name): MRI ASSOCIATES OF ILLINOIS SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2005
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11600 S KEDZIE AVE
MERRIONETTE PARK IL
60803-6302
US

IV. Provider business mailing address

1455 BROAD ST FL 4
BLOOMFIELD NJ
07003-3003
US

V. Phone/Fax

Practice location:
  • Phone: 888-440-6494
  • Fax: 330-759-1501
Mailing address:
  • Phone: 973-707-1100
  • Fax: 973-707-1127

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number StateIL

VIII. Authorized Official

Name: DAVID L BLOOM
Title or Position: PRESIDENT
Credential: MD
Phone: 973-707-1100