Provider Demographics
NPI:1558347567
Name:OPEN MRI OF CONNELLSVILLE LLC
Entity Type:Organization
Organization Name:OPEN MRI OF CONNELLSVILLE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TREASURER
Authorized Official - Prefix:MR
Authorized Official - First Name:JACE
Authorized Official - Middle Name:D
Authorized Official - Last Name:KELLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:724-925-2280
Mailing Address - Street 1:PO BOX 450
Mailing Address - Street 2:
Mailing Address - City:NEW STANTON
Mailing Address - State:PA
Mailing Address - Zip Code:15672-0450
Mailing Address - Country:US
Mailing Address - Phone:724-925-2330
Mailing Address - Fax:724-925-7816
Practice Address - Street 1:2616 MEMORIAL BLVD
Practice Address - Street 2:
Practice Address - City:CONNELLSVILLE
Practice Address - State:PA
Practice Address - Zip Code:15425-1418
Practice Address - Country:US
Practice Address - Phone:724-620-2812
Practice Address - Fax:724-620-2815
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)
Not Answered261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA011682OtherHIGHMARK BCBS
PA0018227030003Medicaid
PA011682OtherHIGHMARK BCBS