Provider Demographics
NPI:1598703589
Name:OPENSIDED MRI OF ST LOUIS, LLC
Entity type:Organization
Organization Name:OPENSIDED MRI OF ST LOUIS, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:S
Authorized Official - Last Name:MOON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-514-0167
Mailing Address - Street 1:12101 OLIVE BLVD
Mailing Address - Street 2:
Mailing Address - City:CREVE COEUR
Mailing Address - State:MO
Mailing Address - Zip Code:63141-6628
Mailing Address - Country:US
Mailing Address - Phone:314-514-0167
Mailing Address - Fax:314-514-8773
Practice Address - Street 1:12101 OLIVE BLVD
Practice Address - Street 2:
Practice Address - City:CREVE COEUR
Practice Address - State:MO
Practice Address - Zip Code:63141-6628
Practice Address - Country:US
Practice Address - Phone:314-514-0167
Practice Address - Fax:314-514-8773
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-03
Last Update Date:2025-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000000488078OtherBCBS PIN
MO503823304Medicaid
MO000093008Medicare ID - Type Unspecified