Provider Demographics
NPI:1902809064
Name:BOSTON OPEN MRI, LLC
Entity Type:Organization
Organization Name:BOSTON OPEN MRI, LLC
Other - Org Name:
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 1:385 WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02135-1005
Mailing Address - Country:US
Mailing Address - Phone:617-782-1690
Mailing Address - Fax:617-782-1735
Practice Address - Street 1:385 WESTERN AVE
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:MA
Practice Address - Zip Code:02135-1005
Practice Address - Country:US
Practice Address - Phone:617-782-1690
Practice Address - Fax:617-782-1735
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2471M1202XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistMagnetic Resonance ImagingGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1531760Medicaid
MA1531760Medicaid