Provider Demographics
NPI:1093770851
Name:OPEN ADVANCED MRI OF CRYSTAL LAKE, LLC
Entity Type:Organization
Organization Name:OPEN ADVANCED MRI OF CRYSTAL LAKE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:PAT
Authorized Official - Last Name:HOULIHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-444-1330
Mailing Address - Street 1:820 E TERRA COTTA AVE
Mailing Address - Street 2:SUITE 136
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60014-3649
Mailing Address - Country:US
Mailing Address - Phone:815-444-1330
Mailing Address - Fax:815-444-1279
Practice Address - Street 1:820 E TERRA COTTA AVE
Practice Address - Street 2:SUITE 136
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-3649
Practice Address - Country:US
Practice Address - Phone:815-444-1330
Practice Address - Fax:815-444-1279
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILCK3870OtherRAILROAD MEDICARE
IL05630041OtherBLUE SHIELD
ILCK3870OtherRAILROAD MEDICARE