1528013992 NPI number — OPEN MRI OF DELAFIELD, LLC

Table of content: (NPI 1528013992)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528013992 NPI number — OPEN MRI OF DELAFIELD, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OPEN MRI OF DELAFIELD, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1528013992
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/01/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1616 E ROOSEVELT RD
Provider Second Line Business Mailing Address:
SUITE 5
Provider Business Mailing Address City Name:
WHEATON
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60187-6850
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
877-444-4540
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3960 HILLSIDE DR
Provider Second Line Business Practice Location Address:
SUITE 106
Provider Business Practice Location Address City Name:
DELAFIELD
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53018-2148
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
262-646-6950
Provider Business Practice Location Address Fax Number:
262-646-7098
Provider Enumeration Date:
05/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SAGE
Authorized Official First Name:
EDWIN
Authorized Official Middle Name:
Authorized Official Title or Position:
MEMBER MANAGER
Authorized Official Telephone Number:
877-444-4540

Provider Taxonomy Codes

  • Taxonomy code: 261QM1200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QR0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: P000043204 . This is a "RAIL ROAD PIN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 21263000 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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