Provider Demographics
NPI:1023444890
Name:BUCKTOWN OPEN MRI, LLC
Entity type:Organization
Organization Name:BUCKTOWN 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:
Authorized Official - Last Name:SAGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-772-9988
Mailing Address - Street 1:1717 N ASHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-1449
Mailing Address - Country:US
Mailing Address - Phone:773-772-9988
Mailing Address - Fax:773-772-9989
Practice Address - Street 1:1717 N ASHLAND AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-1449
Practice Address - Country:US
Practice Address - Phone:773-772-9988
Practice Address - Fax:773-772-9989
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-24
Last Update Date:2013-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)
No261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology