MEDICARE: WIDE OPEN MRI OF BULLHEAD CITY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM1200X	Magnetic Resonance Imaging (MRI) Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	AZ0769960	OTHER	AZ	BLUE CROSS

General Provider Information

NPI Number	:	1639105893
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WIDE OPEN MRI OF BULLHEAD CITY LLC

Provider Business Mailing Address
First Line	:	2000 HIGHWAY 95
Second Line	:	SUITE 222
City	:	BULLHEAD CITY
State	:	AZ
Zip	:	86442-6050
Country	:	US
Telephone Number	:	928-704-0080
Fax Number	:	928-704-1654

Provider Business Practice Location Address
First Line	:	2000 HIGHWAY 95
Second Line	:	SUITE 222
City	:	BULLHEAD CITY
State	:	AZ
Zip	:	86442-6050
Country	:	US
Telephone Number	:	928-704-0080
Fax Number	:	928-704-1654

Authorized Official
Title or Position	:	OWNER
Name	:	JASON A CYRUS
Credential	:
Telephone Number	:	928-704-0080

Provider Enumeration Date	:	06/22/2006
Last Update Date	:	06/07/2011

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Directions to “WIDE OPEN MRI OF BULLHEAD CITY LLC ” Practice Location

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