Healthcare Provider Details

I. General information

NPI: 1609822683
Provider Name (Legal Business Name): OPEN ADVANCED MRI OF GRESHAM LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2006
Last Update Date: 01/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1026 NW SLERET AVE
GRESHAM OR
97030
US

IV. Provider business mailing address

DEPARTMENT 4888
CAROL STREAM IL
60122-4888
US

V. Phone/Fax

Practice location:
  • Phone: 503-489-1674
  • Fax: 503-489-1678
Mailing address:
  • Phone: 503-657-8663
  • Fax: 503-723-3180

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier7113541
Identifier TypeMEDICAID
Identifier StateWA
Identifier Issuer
# 2
Identifier286947
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name: LEVENT ADAM
Title or Position: DIRECTOR OF OPERATIONS
Credential:
Phone: 703-970-2892