Provider Demographics
NPI:1033211867
Name:MEDFORD OPEN IMAGING, LLC
Entity Type:Organization
Organization Name:MEDFORD OPEN IMAGING, LLC
Other - Org Name:MEDFORD OPEN MRI, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:D
Authorized Official - Last Name:FREEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD DC MPH
Authorized Official - Phone:503-586-0153
Mailing Address - Street 1:205 LIBERTY ST NE
Mailing Address - Street 2:SUITE B
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-3586
Mailing Address - Country:US
Mailing Address - Phone:503-586-0153
Mailing Address - Fax:
Practice Address - Street 1:1174 PROGRESS DR
Practice Address - Street 2:SUITE 101
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-4994
Practice Address - Country:US
Practice Address - Phone:541-857-8563
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-02
Last Update Date:2008-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR261QM1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR114183Medicare ID - Type Unspecified