Basic Information
| Provider Information | |||||||||
| NPI: | 1790720936 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OPEN MRI OF MISSOURI, L.L.C. | ||||||||
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| OtherOrganizationName: | NYDIC OPEN MRI OF AMERICA-ST. LOUIS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 PARAGON DR | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | MONTVALE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 076451779 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2015738080 | ||||||||
| FaxNumber: | 2017754306 | ||||||||
| Practice Location | |||||||||
| Address1: | 1034 S BRENTWOOD BLVD | ||||||||
| Address2: | SUITE 111 | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631171223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3148630084 | ||||||||
| FaxNumber: | 3148630096 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | BUCHWALTER | ||||||||
| AuthorizedOfficialFirstName: | LAWRENCE | ||||||||
| AuthorizedOfficialMiddleName: | M. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 2015738080 | ||||||||
| IsSoleProprietor: | |||||||||
| 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 | 17064 | 01 | MO | MEDFOCUS | OTHER | QMXPRO249467 | 01 | MO | ALLIANCE BLUECHOICE | OTHER | 5052580 | 01 | MO | AETNA US HEALTHCARE | OTHER | 394937 | 01 | MO | HEALTHLINK | OTHER | 11159 | 01 | MO | HEALTHCARE USA | OTHER | 16-00435 | 01 | MO | UNITED HEALTHCARE OF MO | OTHER | 194356 | 01 | MO | BCBS OF MISSOURI | OTHER | 33820 | 01 | MO | GROUP HEALTH PLAN | OTHER |