Basic Information
| Provider Information | |||||||||
| NPI: | 1306883616 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OPEN AND WIDE MRI LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 338 | ||||||||
| Address2: | |||||||||
| City: | LA FONTAINE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 469400338 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7652284660 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3050 WINDSOR COURT | ||||||||
| Address2: | |||||||||
| City: | ELKHART | ||||||||
| State: | IN | ||||||||
| PostalCode: | 465145555 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5742669222 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2006 | ||||||||
| LastUpdateDate: | 08/17/2021 | ||||||||
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| AuthorizedOfficialLastName: | BARTROM | ||||||||
| AuthorizedOfficialFirstName: | GARDNER | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7652284660 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 08/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 200415560 | 05 | IN | MEDICAID | CK6657 | 01 | IN | RAILROAD MEDICARE | OTHER |