Provider Demographics
NPI:1336114446
Name:OPEN DIAGNOSTIC IMAGING, LLC
Entity Type:Organization
Organization Name:OPEN DIAGNOSTIC IMAGING, LLC
Other - Org Name:WILLOWBEND DIAGNOSTIC IMAGING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:
Authorized Official - Last Name:CUNNINGHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-826-8822
Mailing Address - Street 1:5025 W PARK BLVD
Mailing Address - Street 2:SUITE 500
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75093-2584
Mailing Address - Country:US
Mailing Address - Phone:972-596-1934
Mailing Address - Fax:972-596-4934
Practice Address - Street 1:5025 W PARK BLVD
Practice Address - Street 2:SUITE 500
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75093-2584
Practice Address - Country:US
Practice Address - Phone:972-596-1934
Practice Address - Fax:972-596-4934
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-22
Last Update Date:2008-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXR25645261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1446932-02Medicaid
TX00089TMedicare ID - Type Unspecified