Provider Demographics
NPI:1780655282
Name:INDIANA OPEN MRI LLC
Entity Type:Organization
Organization Name:INDIANA OPEN MRI 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 1:1265 WAYNE AVE
Practice Address - Street 2:SUITE 305
Practice Address - City:INDIANA
Practice Address - State:PA
Practice Address - Zip Code:15701-3501
Practice Address - Country:US
Practice Address - Phone:724-349-3110
Practice Address - Fax:724-349-3149
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
N/A261QM1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1012169940001Medicaid
PA1689483OtherHIGHMARK BCBS
PA1689483OtherHIGHMARK BCBS