1790720936 NPI number — OPEN MRI OF MISSOURI, L.L.C.

Table of content: (NPI 1790720936)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790720936 NPI number — OPEN MRI OF MISSOURI, L.L.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OPEN MRI OF MISSOURI, L.L.C.
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:
NYDIC OPEN MRI OF AMERICA-ST. LOUIS
Provider Other Organization Name Type Code:
3
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:
1790720936
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 PARAGON DR
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
MONTVALE
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07645-1779
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
201-573-8080
Provider Business Mailing Address Fax Number:
201-775-4306

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1034 S BRENTWOOD BLVD
Provider Second Line Business Practice Location Address:
SUITE 111
Provider Business Practice Location Address City Name:
SAINT LOUIS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63117-1223
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-863-0084
Provider Business Practice Location Address Fax Number:
314-863-0096
Provider Enumeration Date:
06/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BUCHWALTER
Authorized Official First Name:
LAWRENCE
Authorized Official Middle Name:
M.
Authorized Official Title or Position:
PRESIDENT/CEO
Authorized Official Telephone Number:
201-573-8080

Provider Taxonomy Codes

  • Taxonomy code: 261QM1200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 261QR0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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

  • Identifier: 17064 . This is a "MEDFOCUS" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: QMXPRO249467 . This is a "ALLIANCE BLUECHOICE" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 5052580 . This is a "AETNA US HEALTHCARE" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 394937 . This is a "HEALTHLINK" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 11159 . This is a "HEALTHCARE USA" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 16-00435 . This is a "UNITED HEALTHCARE OF MO" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 194356 . This is a "BCBS OF MISSOURI" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 33820 . This is a "GROUP HEALTH PLAN" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




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