1598703589 NPI number — OPENSIDED MRI OF ST LOUIS, 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 1598703589 NPI number — OPENSIDED MRI OF ST LOUIS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OPENSIDED MRI OF ST LOUIS, 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:
6
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:
1598703589
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/14/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12101 OLIVE BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CREVE COEUR
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63141-6628
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-514-0167
Provider Business Mailing Address Fax Number:
314-514-8773

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12101 OLIVE BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CREVE COEUR
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63141-6628
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-514-0167
Provider Business Practice Location Address Fax Number:
314-514-8773
Provider Enumeration Date:
06/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MOON
Authorized Official First Name:
JENNIFER
Authorized Official Middle Name:
S
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
314-514-0167

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: 000000488078 . This is a "BCBS PIN" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 503823304 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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