MEDICARE: OPEN ADVANCED MRI OF PLAINFIELD, 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	DB4311	OTHER	IL	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	09932181	OTHER	IL	BLUE SHIELD

General Provider Information

NPI Number	:	1902861750
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OPEN ADVANCED MRI OF PLAINFIELD, LLC

Provider Business Mailing Address
First Line	:	4714 CATON FARM RD
Second Line	:
City	:	PLAINFIELD
State	:	IL
Zip	:	60586-8350
Country	:	US
Telephone Number	:	815-609-4988
Fax Number	:	815-609-4989

Provider Business Practice Location Address
First Line	:	4714 CATON FARM RD
Second Line	:
City	:	PLAINFIELD
State	:	IL
Zip	:	60586-8350
Country	:	US
Telephone Number	:	815-609-4988
Fax Number	:	815-609-4989

Authorized Official
Title or Position	:	DIRECTOR
Name	:	JERRY ZEMELA
Credential	:
Telephone Number	:	815-609-4988

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

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