MEDICARE: STREETERVILLE OPEN MRI, 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	261QM1200X	Magnetic Resonance Imaging (MRI) Clinic/Center
2	261QR0200X	Radiology Clinic/Center	036068882	IL

General Provider Information

NPI Number	:	1518999614
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STREETERVILLE OPEN MRI, LLC

Provider Business Mailing Address
First Line	:	1616 E ROOSEVELT RD
Second Line	:	SUITE 5
City	:	WHEATON
State	:	IL
Zip	:	60187-6850
Country	:	US
Telephone Number	:	877-444-4540
Fax Number	:	847-550-1488

Provider Business Practice Location Address
First Line	:	446 E ONTARIO ST
Second Line	:	SUITE 106
City	:	CHICAGO
State	:	IL
Zip	:	60611-4418
Country	:	US
Telephone Number	:	312-440-0016
Fax Number	:	312-440-0017

Authorized Official
Title or Position	:	MEMBER MANAGER
Name	:	MR. EDWIN C SAGE
Credential	:
Telephone Number	:	877-444-4540

Provider Enumeration Date	:	07/07/2006
Last Update Date	:	01/11/2012

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