Basic Information
| Provider Information | |||||||||
| NPI: | 1699737486 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NYDIC OPEN MRI OF AMERICA-LAFAYETTE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 PARAGON DR | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | MONTVALE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 076451718 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2015738080 | ||||||||
| FaxNumber: | 2017754306 | ||||||||
| Practice Location | |||||||||
| Address1: | 600 GUILBEAU RD | ||||||||
| Address2: | SUITE 6 | ||||||||
| City: | LAFAYETTE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705068405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3379840002 | ||||||||
| FaxNumber: | 3379840003 | ||||||||
| 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 | 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 | 21500 | 01 | LA | MEDFOCUS | OTHER | 1236965 | 01 | LA | FIRST HEALTH NETWORK | OTHER | 1949515 | 05 | LA | MEDICAID | 1600912 | 01 | LA | UNITED HEALTHCARE | OTHER | A-91984 | 01 | LA | MULTIPLAN | OTHER |