Basic Information
| Provider Information | |||||||||
| NPI: | 1558346148 | ||||||||
| 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: | 606895311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3148218055 | ||||||||
| FaxNumber: | 3148211833 | ||||||||
| Practice Location | |||||||||
| Address1: | 3050 WINDSOR CT | ||||||||
| Address2: | |||||||||
| City: | ELKHART | ||||||||
| State: | IN | ||||||||
| PostalCode: | 465145555 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5742669222 | ||||||||
| FaxNumber: | 5742669333 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/07/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | KOSTKA | ||||||||
| AuthorizedOfficialFirstName: | RANDY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5742669222 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2471M1202X | 20590 | IN | Y | 193400000X SINGLE SPECIALTY GROUP | Technologists, Technicians & Other Technical Service Providers | Radiologic Technologist | Magnetic Resonance Imaging |
ID Information
| ID | Type | State | Issuer | Description | 000000275391 | 01 | IN | BCBS | OTHER | 1604490821 | 05 | MI | MEDICAID | 14506 | 01 | PHP | OTHER |