Basic Information
| Provider Information | |||||||||
| NPI: | 1235185513 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OPEN AND WIDE MRI LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1732 MOMENTUM PL | ||||||||
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| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606895317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8887199036 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2856 EISENHOWER DR N. | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | GOSHEN | ||||||||
| State: | IN | ||||||||
| PostalCode: | 46528 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5742669222 | ||||||||
| FaxNumber: | 5742669333 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | JONES | ||||||||
| AuthorizedOfficialFirstName: | APRIL | ||||||||
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| AuthorizedOfficialTitleorPosition: | CLIENT REPRESENTATIVE | ||||||||
| AuthorizedOfficialTelephone: | 3304939004 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.