=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396002309
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AMERICAN DIAGNOSTIC MRI LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/13/2012
-----------------------------------------------------
Last Update Date | 04/13/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 360 W BUTTERFIELD RD SUITE 130
-----------------------------------------------------
City | ELMHURST
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60126-5068
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-333-4674
-----------------------------------------------------
Fax | 630-333-4567
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 360 W BUTTERFIELD RD SUITE 130
-----------------------------------------------------
City | ELMHURST
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60126-5068
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-333-4674
-----------------------------------------------------
Fax | 630-333-4567
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | MARVIN TAZELAAR
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 630-333-4674
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM1200X
-----------------------------------------------------
Taxonomy Name | Magnetic Resonance Imaging (MRI) Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------