Provider Demographics
NPI:1558346148
Name:OPEN AND WIDE MRI, LLC
Entity Type:Organization
Organization Name:OPEN AND WIDE MRI, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GARDNER
Authorized Official - Middle Name:
Authorized Official - Last Name:BARTROM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:765-228-4660
Mailing Address - Street 1:PO BOX 338
Mailing Address - Street 2:
Mailing Address - City:LA FONTAINE
Mailing Address - State:IN
Mailing Address - Zip Code:46940-0338
Mailing Address - Country:US
Mailing Address - Phone:765-228-4660
Mailing Address - Fax:765-228-4660
Practice Address - Street 1:3050 WINDSOR CT
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-5555
Practice Address - Country:US
Practice Address - Phone:574-266-9222
Practice Address - Fax:574-266-9333
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-07
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN205902471M1202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2471M1202XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistMagnetic Resonance ImagingGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1604490821Medicaid
IN000000275391OtherBCBS
14506OtherPHP
IN200415560AMedicaid