Provider Demographics
NPI:1760400204
Name:DEDHAM MRI INC
Entity Type:Organization
Organization Name:DEDHAM MRI INC
Other - Org Name:OPEN MRI OF DEDHAM
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:VALLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-873-9850
Mailing Address - Street 1:1455 BROAD ST
Mailing Address - Street 2:4TH FLOOR
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07003
Mailing Address - Country:US
Mailing Address - Phone:973-873-9889
Mailing Address - Fax:973-707-1127
Practice Address - Street 1:200 PROVIDENCE HWY ROUTE 1
Practice Address - Street 2:STE 210
Practice Address - City:DEDHAM
Practice Address - State:MA
Practice Address - Zip Code:02026
Practice Address - Country:US
Practice Address - Phone:781-329-0600
Practice Address - Fax:781-329-1713
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-17
Last Update Date:2009-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1528980Medicaid
MA327121Medicare PIN