1184670754 NPI number — OPEN ADVANCED MRI PORTLAND III, LLC

Table of content: (NPI 1184670754)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184670754 NPI number — OPEN ADVANCED MRI PORTLAND III, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OPEN ADVANCED MRI PORTLAND III, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1184670754
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/27/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 75469
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BALTIMORE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21275-5469
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-657-8663
Provider Business Mailing Address Fax Number:
503-723-3180

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11750 SE 82ND AVE
Provider Second Line Business Practice Location Address:
#J
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97266-7727
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-653-1699
Provider Business Practice Location Address Fax Number:
503-653-3899
Provider Enumeration Date:
05/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ADAM
Authorized Official First Name:
LEVENT
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF OPERATIONS
Authorized Official Telephone Number:
703-970-2892

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 130242 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7114648 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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