Basic Information
Provider Information | |||||||||
NPI: | 1730124918 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | OPEN MRI OF MISSOURI II, L.L.C. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | NYDIC OPEN MRI OF AMERICA-ST. PETERS | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 100 PARAGON DR | ||||||||
Address2: | SUITE 200 | ||||||||
City: | MONTVALE | ||||||||
State: | NJ | ||||||||
PostalCode: | 076451779 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2015738080 | ||||||||
FaxNumber: | 2017754306 | ||||||||
Practice Location | |||||||||
Address1: | 5650 MEXICO RD | ||||||||
Address2: | SUITE 10 | ||||||||
City: | SAINT PETERS | ||||||||
State: | MO | ||||||||
PostalCode: | 633761696 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6364777277 | ||||||||
FaxNumber: | 6364777377 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/19/2006 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BUCHWALTER | ||||||||
AuthorizedOfficialFirstName: | LAWRENCE | ||||||||
AuthorizedOfficialMiddleName: | M. | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
AuthorizedOfficialTelephone: | 2015738080 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
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 | 17066 | 01 | MO | MEDFOCUS | OTHER | 30533 | 01 | MO | GROUP HEALTH PLAN | OTHER | 5927645 | 01 | MO | AETNA US HEALTHCARE | OTHER | QMXPRO249646 | 01 | MO | ALLIANCE BLUECHOICE | OTHER | 399695 | 01 | MO | HEALTHLINK | OTHER | 11720 | 01 | MO | HEALTHCARE USA | OTHER | 16-00435 | 01 | MO | UNITED HEALTHCARE OF MO | OTHER | 194359 | 01 | MO | BCBS OF MISSOURI | OTHER |