Provider Demographics
NPI:1659488161
Name:JENNERSVILLE OPEN MRI AND IMAGING CENTER, LLC
Entity Type:Organization
Organization Name:JENNERSVILLE OPEN MRI AND IMAGING CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:ROLLINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:610-869-8889
Mailing Address - Street 1:900 W BALTIMORE PIKE
Mailing Address - Street 2:
Mailing Address - City:WEST GROVE
Mailing Address - State:PA
Mailing Address - Zip Code:19390-9313
Mailing Address - Country:US
Mailing Address - Phone:610-869-8889
Mailing Address - Fax:610-869-7688
Practice Address - Street 1:900 W BALTIMORE PIKE
Practice Address - Street 2:SUITE 102
Practice Address - City:WEST GROVE
Practice Address - State:PA
Practice Address - Zip Code:19390
Practice Address - Country:US
Practice Address - Phone:610-869-8889
Practice Address - Fax:610-869-7688
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-23
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA36881692085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1019122220001Medicaid