Healthcare Provider Details

I. General information

NPI: 1710932645
Provider Name (Legal Business Name): NORTHERN OPEN MRI LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1955 DEKALB AVE
SYCAMORE IL
60178-3107
US

IV. Provider business mailing address

1955 DEKALB AVE
SYCAMORE IL
60178-3107
US

V. Phone/Fax

Practice location:
  • Phone: 817-754-4100
  • Fax: 815-754-4141
Mailing address:
  • Phone: 817-754-4100
  • Fax: 815-754-4141

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1200X
TaxonomyMagnetic Resonance Imaging (MRI) Clinic/Center
License Number
License Number StateIL

VIII. Authorized Official

Name: PANNA GOSWAMI
Title or Position: OWNER
Credential: M.D.
Phone: 815-754-4100