Provider Demographics
NPI:1932125952
Name:OPEN MRI OF FAIRVIEW
Entity Type:Organization
Organization Name:OPEN MRI OF FAIRVIEW
Other - Org Name:SUPERIOR MEDICAL IMAGING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:A
Authorized Official - Last Name:GAGLIANO
Authorized Official - Suffix:
Authorized Official - Credentials:RT CXT
Authorized Official - Phone:201-941-7575
Mailing Address - Street 1:178 BERGEN BLVD
Mailing Address - Street 2:PO BOX 99
Mailing Address - City:FAIRVIEW
Mailing Address - State:NJ
Mailing Address - Zip Code:07022
Mailing Address - Country:US
Mailing Address - Phone:201-941-7575
Mailing Address - Fax:201-941-1660
Practice Address - Street 1:178 BERGEN BLVD
Practice Address - Street 2:
Practice Address - City:FAIRVIEW
Practice Address - State:NJ
Practice Address - Zip Code:07022
Practice Address - Country:US
Practice Address - Phone:201-941-7575
Practice Address - Fax:201-941-1660
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22693261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8000603Medicaid
NJ020882Medicare ID - Type Unspecified