Provider Demographics
NPI:1376546390
Name:JAMESTOWN IMAGING MANAGEMENT LLC
Entity Type:Organization
Organization Name:JAMESTOWN IMAGING MANAGEMENT LLC
Other - Org Name:JAMESTOWN OPEN MRI
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:DOUGLAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-403-1401
Mailing Address - Street 1:15 S MAIN ST STE 250
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:14701-6626
Mailing Address - Country:US
Mailing Address - Phone:716-665-1198
Mailing Address - Fax:716-665-2035
Practice Address - Street 1:779 FAIRMOUNT AVE
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:NY
Practice Address - Zip Code:14701-2608
Practice Address - Country:US
Practice Address - Phone:716-665-1198
Practice Address - Fax:716-665-2035
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-23
Last Update Date:2008-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
No261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYBA0094Medicare PIN