Provider Demographics
NPI:1154455764
Name:MED TEL INTERNATIONAL CORPORATION
Entity Type:Organization
Organization Name:MED TEL INTERNATIONAL CORPORATION
Other - Org Name:WIDE OPEN MRI
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:VALLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-873-9850
Mailing Address - Street 1:1430 SPRING HILL RD
Mailing Address - Street 2:SUITE 500
Mailing Address - City:MCLEAN
Mailing Address - State:VA
Mailing Address - Zip Code:22102-3000
Mailing Address - Country:US
Mailing Address - Phone:703-287-4189
Mailing Address - Fax:703-448-8515
Practice Address - Street 1:6545 W CENTRAL AVE
Practice Address - Street 2:SUIE 104
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43617-1089
Practice Address - Country:US
Practice Address - Phone:419-841-0505
Practice Address - Fax:419-841-0059
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MED TEL INTERNATIONAL CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-15
Last Update Date:2008-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0443IC261QM1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2033829Medicaid
OH2033829Medicaid