MEDICARE: OPEN MRI OF FAIRVIEW

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	261QR0200X	Radiology Clinic/Center	22693	NJ

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	:	1932125952
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OPEN MRI OF FAIRVIEW

Provider Business Mailing Address
First Line	:	178 BERGEN BLVD
Second Line	:	PO BOX 99
City	:	FAIRVIEW
State	:	NJ
Zip	:	07022
Country	:	US
Telephone Number	:	201-941-7575
Fax Number	:	201-941-1660

Provider Business Practice Location Address
First Line	:	178 BERGEN BLVD
Second Line	:
City	:	FAIRVIEW
State	:	NJ
Zip	:	07022
Country	:	US
Telephone Number	:	201-941-7575
Fax Number	:	201-941-1660

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	LISA A GAGLIANO
Credential	:	RT CXT
Telephone Number	:	201-941-7575

Provider Enumeration Date	:	07/14/2006
Last Update Date	:	08/22/2020

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