Provider Demographics
NPI:1639105893
Name:WIDE OPEN MRI OF BULLHEAD CITY LLC
Entity Type:Organization
Organization Name:WIDE OPEN MRI OF BULLHEAD CITY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:A
Authorized Official - Last Name:CYRUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-704-0080
Mailing Address - Street 1:2000 HIGHWAY 95
Mailing Address - Street 2:SUITE 222
Mailing Address - City:BULLHEAD CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86442-6050
Mailing Address - Country:US
Mailing Address - Phone:928-704-0080
Mailing Address - Fax:928-704-1654
Practice Address - Street 1:2000 HIGHWAY 95
Practice Address - Street 2:SUITE 222
Practice Address - City:BULLHEAD CITY
Practice Address - State:AZ
Practice Address - Zip Code:86442-6050
Practice Address - Country:US
Practice Address - Phone:928-704-0080
Practice Address - Fax:928-704-1654
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-22
Last Update Date:2011-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ912776Medicaid
AZAZ0769960OtherBLUE CROSS
AZZ101685Medicare PIN