MEDICARE: WEST BEND OPEN MRI, 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		WI

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

General Provider Information

NPI Number	:	1457356321
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WEST BEND OPEN MRI, LLC

Provider Business Mailing Address
First Line	:	1016 GATEWAY CT
Second Line	:
City	:	WEST BEND
State	:	WI
Zip	:	53095-8541
Country	:	US
Telephone Number	:	262-334-7674
Fax Number	:	262-334-7692

Provider Business Practice Location Address
First Line	:	1016 GATEWAY CT
Second Line	:
City	:	WEST BEND
State	:	WI
Zip	:	53095-8541
Country	:	US
Telephone Number	:	262-334-7674
Fax Number	:	262-334-7692

Authorized Official
Title or Position	:	MANAGER
Name	:	MR. STEVEN A. METCALF
Credential	:	MBA
Telephone Number	:	262-334-7674

Provider Enumeration Date	:	06/16/2005
Last Update Date	:	08/22/2020

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