Provider Demographics
NPI:1841293552
Name:EAUCLAIRE OPEN MRI, LLC
Entity type:Organization
Organization Name:EAUCLAIRE OPEN MRI, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:DOUGLAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-477-1815
Mailing Address - Street 1:4130 STATE HWY 93
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701-7806
Mailing Address - Country:US
Mailing Address - Phone:715-830-9507
Mailing Address - Fax:715-830-9609
Practice Address - Street 1:4130 STATE ROAD 93
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-7806
Practice Address - Country:US
Practice Address - Phone:715-830-9507
Practice Address - Fax:715-830-9609
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-27
Last Update Date:2008-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32880400Medicaid
WI92023Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER