MEDICARE: LAKE ZURICH 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

General Provider Information

NPI Number	:	1790944197
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKE ZURICH OPEN MRI, LLC

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

Provider Business Practice Location Address
First Line	:	721 W HIGHWAY 22
Second Line	:
City	:	LAKE ZURICH
State	:	IL
Zip	:	60047-2552
Country	:	US
Telephone Number	:	847-726-0674
Fax Number	:	847-726-0675

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

Provider Enumeration Date	:	06/02/2008
Last Update Date	:	11/16/2012

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