Basic Information
| Provider Information | |||||||||
| NPI: | 1841252608 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NYDIC OPEN MRI OF AMERICA-KETTERING, 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: | 580 LINCOLN PARK BLVD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | KETTERING | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454293474 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372983510 | ||||||||
| FaxNumber: | 9372984231 | ||||||||
| 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 | 0839IC | OH | 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 | 16-97244 | 01 | OH | UNITED HEALTHCARE OF OH | OTHER | 175270 | 01 | OH | UNISON HEALTH PLAN | OTHER | 000000039115 | 01 | OH | ANTHEM BCBS | OTHER | 8463210 | 01 | OH | AETNA | OTHER | 21502 | 01 | OH | MEDFOCUS | OTHER | 37523 | 01 | OH | NATIONWIDE HEALTH PLANS | OTHER | 16-97244 | 01 | OH | UHC OF OHIO | OTHER | 2433610 | 05 | OH | MEDICAID |