Provider Demographics
NPI:1396002309
Name:AMERICAN DIAGNOSTIC MRI LLC
Entity Type:Organization
Organization Name:AMERICAN DIAGNOSTIC MRI LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:TAZELAAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-333-4674
Mailing Address - Street 1:360 W BUTTERFIELD RD
Mailing Address - Street 2:SUITE 130
Mailing Address - City:ELMHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60126-5068
Mailing Address - Country:US
Mailing Address - Phone:630-333-4674
Mailing Address - Fax:630-333-4567
Practice Address - Street 1:360 W BUTTERFIELD RD
Practice Address - Street 2:SUITE 130
Practice Address - City:ELMHURST
Practice Address - State:IL
Practice Address - Zip Code:60126-5068
Practice Address - Country:US
Practice Address - Phone:630-333-4674
Practice Address - Fax:630-333-4567
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-13
Last Update Date:2012-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL4853951OtherLISC