Provider Demographics
NPI:1356563589
Name:EFFINGHAM OPEN MRI, LLC
Entity type:Organization
Organization Name:EFFINGHAM OPEN MRI, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:R
Authorized Official - Last Name:HORACE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-347-6736
Mailing Address - Street 1:500 N MAPLE ST STE A
Mailing Address - Street 2:
Mailing Address - City:EFFINGHAM
Mailing Address - State:IL
Mailing Address - Zip Code:62401-2005
Mailing Address - Country:US
Mailing Address - Phone:217-347-6736
Mailing Address - Fax:217-347-5573
Practice Address - Street 1:500 N MAPLE ST STE A
Practice Address - Street 2:
Practice Address - City:EFFINGHAM
Practice Address - State:IL
Practice Address - Zip Code:62401-2005
Practice Address - Country:US
Practice Address - Phone:217-347-6736
Practice Address - Fax:217-347-5573
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2009-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
205899Medicare PIN