Basic Information
| Provider Information | |||||||||
| NPI: | 1649232455 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NYDIC OPEN MRI OF AMERICA-MAHWAH VALLEY, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 PARAGON DR | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | MONTVALE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 076451718 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2015738080 | ||||||||
| FaxNumber: | 2017754306 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 FRANKLIN TPKE | ||||||||
| Address2: | SUITE B | ||||||||
| City: | MAHWAH | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 074303516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2017609500 | ||||||||
| FaxNumber: | 2017600295 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/05/2006 | ||||||||
| 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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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1200X | 22517 | NJ | X | Ambulatory Health Care Facilities | Clinic/Center | Magnetic Resonance Imaging (MRI) | 261QR0200X | X | Ambulatory Health Care Facilities | Clinic/Center | Radiology |
ID Information
| ID | Type | State | Issuer | Description | 4196850 | 01 | NJ | GHI | OTHER | 1440067 | 01 | NJ | UNITED HEALTHCARE OF NJ | OTHER | WS5721 | 01 | NJ | WELLCHOICE | OTHER | 22160 | 01 | NJ | MEDFOCUS | OTHER | 3082416 | 01 | NJ | CIGNA PPO | OTHER | 22911 | 01 | NJ | UNIVERSITY HEALTH PLAN | OTHER | 7419309 | 05 | NJ | MEDICAID | 2K1317 | 01 | NJ | HEALTHNET | OTHER | 5922493 | 01 | NJ | AETNA NON-HMO | OTHER | A463305 | 01 | NJ | OXFORD | OTHER | 1078395 | 01 | NJ | FIRST HEALTH NETWORK | OTHER | 2819104 | 01 | NJ | AETNA HMO | OTHER | 37574 | 01 | NJ | AMERICAID AMERIGROUP | OTHER |