Provider Demographics
NPI:1306883616
Name:OPEN AND WIDE MRI LLC
Entity type:Organization
Organization Name:OPEN AND WIDE MRI LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GARDNER
Authorized Official - Middle Name:
Authorized Official - Last Name:BARTROM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:765-228-4660
Mailing Address - Street 1:PO BOX 338
Mailing Address - Street 2:
Mailing Address - City:LA FONTAINE
Mailing Address - State:IN
Mailing Address - Zip Code:46940-0338
Mailing Address - Country:US
Mailing Address - Phone:765-228-4660
Mailing Address - Fax:
Practice Address - Street 1:3050 WINDSOR COURT
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-5555
Practice Address - Country:US
Practice Address - Phone:574-266-9222
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-02
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200415560Medicaid
INCK6657OtherRAILROAD MEDICARE
INOW199600Medicare UPIN