Basic Information
| Provider Information | |||||||||
| NPI: | 1033112834 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | OPEN MRI OF FORT WORTH, L.C. | ||||||||
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| OtherOrganizationName: | NYDIC OPEN MRI OF AMERICA-FORT WORTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 PARAGON DR | ||||||||
| Address2: | STE 200 | ||||||||
| City: | MONTVALE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 076451718 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2015738080 | ||||||||
| FaxNumber: | 2017754306 | ||||||||
| Practice Location | |||||||||
| Address1: | 6500 WEST FWY | ||||||||
| Address2: | STE 104 | ||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761162139 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8177635900 | ||||||||
| FaxNumber: | 8177635858 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | BUCHWALTER | ||||||||
| AuthorizedOfficialFirstName: | LAWRENCE | ||||||||
| AuthorizedOfficialMiddleName: | M. | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2015738080 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0200X | X | Ambulatory Health Care Facilities | Clinic/Center | Radiology | 261QM1200X | X | Ambulatory Health Care Facilities | Clinic/Center | Magnetic Resonance Imaging (MRI) |
ID Information
| ID | Type | State | Issuer | Description | 0726397 | 01 | TX | AMERIHEALTH | OTHER | 0026DC | 01 | TX | BCBS OF TEXAS | OTHER | 825242 | 01 | TX | HEALTHSMART PREFERRED CAR | OTHER | A-67817 | 01 | TX | MULTIPLAN | OTHER | 2030111 | 01 | TX | AETNA US HEALTHCARE | OTHER | 3650 | 01 | TX | MEDFOCUS | OTHER | 10013077 | 01 | TX | AMERIGROUP | OTHER | 16-14029 | 01 | TX | UNITED HEALTHCARE OF TX | OTHER | 25504 | 01 | TX | NYLCARE HEALTH PLANS | OTHER |