Healthcare Provider Details

I. General information

NPI: 1528013422
Provider Name (Legal Business Name): ILLINI MRI LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 ILLINI DR
SILVIS IL
61282-1804
US

IV. Provider business mailing address

801 ILLINI DR
SILVIS IL
61282-1804
US

V. Phone/Fax

Practice location:
  • Phone: 309-792-9363
  • Fax: 563-421-3419
Mailing address:
  • Phone: 309-792-9363
  • Fax: 563-421-3419

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MR. CHARLES E BRUHN
Title or Position: CEO
Credential:
Phone: 309-792-4265