Basic Information
| Provider Information | |||||||||
| NPI: | 1275570848 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OPEN MRI OF MICHIGAN LLC | ||||||||
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| OtherOrganizationName: | ST JOHN OPEN MRI OF MICHIGAN LLC | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 67000 | ||||||||
| Address2: | DEPARTMENT 18401 | ||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482671841 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5862284607 | ||||||||
| FaxNumber: | 5862284666 | ||||||||
| Practice Location | |||||||||
| Address1: | 411 W 13 MILE RD | ||||||||
| Address2: | STE 200 | ||||||||
| City: | MADISON HEIGHTS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480711526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2485854569 | ||||||||
| FaxNumber: | 2485854620 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | JESMORE | ||||||||
| AuthorizedOfficialFirstName: | RONALD | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | CORPORATE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5862266987 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | MI | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 0F30087 | 01 | BCBS | OTHER | 8265 | 01 | CAPE | OTHER | P116959 | 01 | BCN OLD PROVIDER # | OTHER | 0N68190 | 01 | HAP | OTHER | 139709 | 01 | GREAT LAKES HEALTH PLAN | OTHER | 7282452 | 01 | AETNA | OTHER | 001269 | 01 | MIDWEST HEALTH PLAN | OTHER | 135843 | 01 | CARE CHOICES | OTHER | 8263818 | 01 | CIGNA | OTHER | QMXPR0021565 | 01 | MOLINA | OTHER | M1670 | 01 | ONE CALL MEDICAL | OTHER | RA16206 | 01 | MCARE | OTHER |