1861570020 NPI number — MAPLE CREST OPEN MRI

Table of content: (NPI 1861570020)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861570020 NPI number — MAPLE CREST OPEN MRI

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MAPLE CREST OPEN MRI
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:
1861570020
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/27/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
840 W KANSAS ST
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
LIBERTY
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
64068-2033
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
816-781-9797
Provider Business Mailing Address Fax Number:
816-781-9793

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
840 W KANSAS AVENUE
Provider Second Line Business Practice Location Address:
STE A
Provider Business Practice Location Address City Name:
LIBERTY
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
64068-2033
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
816-587-1818
Provider Business Practice Location Address Fax Number:
816-505-5004
Provider Enumeration Date:
11/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ROSSOW
Authorized Official First Name:
SCOTT
Authorized Official Middle Name:
LUTHER
Authorized Official Title or Position:
OWNER/PHYSICIAN
Authorized Official Telephone Number:
417-339-9800

Provider Taxonomy Codes

  • Taxonomy code: 2471M1202X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 34425017 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: P00152744 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




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