Provider Demographics
NPI:1669681532
Name:SPINE IMAGING MRI LLC
Entity Type:Organization
Organization Name:SPINE IMAGING MRI LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:EDUARDO
Authorized Official - Middle Name:
Authorized Official - Last Name:BULLON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-647-0000
Mailing Address - Street 1:393 NORTH DUNLAP STREET
Mailing Address - Street 2:SUITE LL40
Mailing Address - City:ST PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104
Mailing Address - Country:US
Mailing Address - Phone:651-647-0000
Mailing Address - Fax:651-645-9000
Practice Address - Street 1:393 NORTH DUNLAP STREET
Practice Address - Street 2:SUITE LL40
Practice Address - City:ST PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104
Practice Address - Country:US
Practice Address - Phone:651-647-0000
Practice Address - Fax:651-645-9000
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN83M805POtherBLUE CROSS
MN99121OtherHEALTH PARTNERS