Provider Demographics
NPI:1194710905
Name:OPEN MRI OF SOUTHERN ILLINOIS LLC
Entity type:Organization
Organization Name:OPEN MRI OF SOUTHERN ILLINOIS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:MCRAE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-659-1167
Mailing Address - Street 1:PO BOX 868
Mailing Address - Street 2:
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62025-0868
Mailing Address - Country:US
Mailing Address - Phone:618-659-1167
Mailing Address - Fax:618-659-1197
Practice Address - Street 1:2016 VADALABENE DR
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62062-6901
Practice Address - Country:US
Practice Address - Phone:618-288-4929
Practice Address - Fax:618-288-4531
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
767760Medicare ID - Type Unspecified