Healthcare Provider Details

I. General information

NPI: 1902809064
Provider Name (Legal Business Name): BOSTON OPEN MRI, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

385 WESTERN AVE
BRIGHTON MA
02135-1005
US

IV. Provider business mailing address

385 WESTERN AVE
BRIGHTON MA
02135-1005
US

V. Phone/Fax

Practice location:
  • Phone: 617-782-1690
  • Fax: 617-782-1735
Mailing address:
  • Phone: 617-782-1690
  • Fax: 617-782-1735

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2471M1202X
TaxonomyMagnetic Resonance Imaging Radiologic Technologist
License Number
License Number State

VIII. Authorized Official

Name: MRS. MICHELLE DOUGLAS
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 502-477-1815