Basic Information
Provider Information | |||||||||
NPI: | 1952358699 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | OPEN MRI OF OMAHA LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | NYDIC OPEN MRI OF AMERICA-OMAHA | ||||||||
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: | 310 REGENCY PKWY | ||||||||
Address2: |   | ||||||||
City: | OMAHA | ||||||||
State: | NE | ||||||||
PostalCode: | 681143791 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4023911600 | ||||||||
FaxNumber: | 4023910700 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/28/2006 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BUCHWALTER | ||||||||
AuthorizedOfficialFirstName: | LAWRENCE | ||||||||
AuthorizedOfficialMiddleName: | M. | ||||||||
AuthorizedOfficialTitleorPosition: | 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 | 03701 | 01 | NE | BCBS OF NEBRASKA | OTHER | 0511881 | 05 | IA |   | MEDICAID | 1600173 | 01 | NE | UNITED HEALTHCARE | OTHER | 96860 | 01 | IA | WELLMARK OF IOWA | OTHER |