1558346148 NPI number — OPEN AND WIDE MRI, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558346148 NPI number — OPEN AND WIDE MRI, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OPEN AND WIDE MRI, 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:
1558346148
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/08/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 338
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LA FONTAINE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46940-0338
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
765-228-4660
Provider Business Mailing Address Fax Number:
765-228-4660

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3050 WINDSOR CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ELKHART
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46514-5555
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
574-266-9222
Provider Business Practice Location Address Fax Number:
574-266-9333
Provider Enumeration Date:
12/07/2005

Additional Information

Authorized Official

Authorized Official Last Name:
BARTROM
Authorized Official First Name:
GARDNER
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
765-228-4660

Provider Taxonomy Codes

  • Taxonomy code: 2471M1202X , with the licence number:  20590 , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1604490821 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000275391 . This is a "BCBS" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 14506 . This is a "PHP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 200415560A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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