1558346148 NPI number — OPEN AND WIDE MRI, LLC

Table of content: (NPI 1558346148)

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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