Provider Demographics
NPI:1639105026
Name:JOLIET OPEN MRI, LLC
Entity Type:Organization
Organization Name:JOLIET OPEN MRI, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:EDWIN
Authorized Official - Middle Name:C
Authorized Official - Last Name:SAGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:877-444-4540
Mailing Address - Street 1:1616 E ROOSEVELT RD
Mailing Address - Street 2:SUITE 5
Mailing Address - City:WHEATON
Mailing Address - State:IL
Mailing Address - Zip Code:60187-6850
Mailing Address - Country:US
Mailing Address - Phone:877-444-4540
Mailing Address - Fax:847-550-1488
Practice Address - Street 1:754 ESSINGTON RD
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-4912
Practice Address - Country:US
Practice Address - Phone:815-741-4100
Practice Address - Fax:815-741-4114
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-25
Last Update Date:2012-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)
No261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL=========001Medicaid