Provider Demographics
NPI:1699870063
Name:BROMENN HEALTHCARE OPEN MRI
Entity type:Organization
Organization Name:BROMENN HEALTHCARE OPEN MRI
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP/CIO/CORPORATE INTEGRITY OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-268-2410
Mailing Address - Street 1:PO BOX 2850
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61702-2850
Mailing Address - Country:US
Mailing Address - Phone:309-454-1400
Mailing Address - Fax:
Practice Address - Street 1:1304 FRANKLIN AVE
Practice Address - Street 2:
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-3558
Practice Address - Country:US
Practice Address - Phone:309-454-1400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1748518282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL205932Medicare ID - Type UnspecifiedOPEN MRI