1467491993 NPI number — OPEN MRI OF ORLANDO INC

Table of content: (NPI 1467491993)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467491993 NPI number — OPEN MRI OF ORLANDO INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OPEN MRI OF ORLANDO INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
LAKESIDE OPEN MRI OF TAVARES
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1467491993
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1879 NIGHTINGALE LN
Provider Second Line Business Mailing Address:
SUITE A-1
Provider Business Mailing Address City Name:
TAVARES
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32778-4363
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
352-742-9211
Provider Business Mailing Address Fax Number:
352-742-9406

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1879 NIGHTINGALE LN
Provider Second Line Business Practice Location Address:
SUITE A-1
Provider Business Practice Location Address City Name:
TAVARES
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32778-4363
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-742-9211
Provider Business Practice Location Address Fax Number:
352-742-9406
Provider Enumeration Date:
06/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WOODBURN
Authorized Official First Name:
SHAUN
Authorized Official Middle Name:
P
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
352-742-9211

Provider Taxonomy Codes

  • Taxonomy code: 261QR0200X , with the licence number:  HCC5152 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: V2544 . This is a "BLUE CROSS AND BLUE SHEIL" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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