MEDICARE: OPEN ADVANCED MRI OF CRYSTAL LAKE, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2085R0202X	Diagnostic Radiology Physician		IL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	CK3870	OTHER	IL	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	05630041	OTHER	IL	BLUE SHIELD

General Provider Information

NPI Number	:	1093770851
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OPEN ADVANCED MRI OF CRYSTAL LAKE, LLC

Provider Business Mailing Address
First Line	:	820 E TERRA COTTA AVE
Second Line	:	SUITE 136
City	:	CRYSTAL LAKE
State	:	IL
Zip	:	60014-3649
Country	:	US
Telephone Number	:	815-444-1330
Fax Number	:	815-444-1279

Provider Business Practice Location Address
First Line	:	820 E TERRA COTTA AVE
Second Line	:	SUITE 136
City	:	CRYSTAL LAKE
State	:	IL
Zip	:	60014-3649
Country	:	US
Telephone Number	:	815-444-1330
Fax Number	:	815-444-1279

Authorized Official
Title or Position	:	DIRECTOR
Name	:	MARY PAT HOULIHAN
Credential	:
Telephone Number	:	815-444-1330

Provider Enumeration Date	:	04/17/2006
Last Update Date	:	08/22/2020

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