1023111804 NPI number — PREMIER MRI SERVICES LLC

Table of content: (NPI 1023111804)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023111804 NPI number — PREMIER MRI SERVICES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PREMIER MRI SERVICES LLC
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:
Provider Other Organization Name Type Code:
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:
1023111804
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/25/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
107 RIDGLEY AVE
Provider Second Line Business Mailing Address:
SUITE 12
Provider Business Mailing Address City Name:
ANNAPOLIS
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21401
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-267-1780
Provider Business Mailing Address Fax Number:
410-267-1784

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
107 RIDGLEY AVE
Provider Second Line Business Practice Location Address:
SUITE 12
Provider Business Practice Location Address City Name:
ANNAPOLIS
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21401
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-267-1780
Provider Business Practice Location Address Fax Number:
410-267-1784
Provider Enumeration Date:
09/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DUBIANSKY
Authorized Official First Name:
WALTER
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO PRESIDENT
Authorized Official Telephone Number:
410-267-1780

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X , with the licence number:  M231 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 9398PR . This is a "BLUE SHIELD OF MARYLAND" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: K646 . This is a "BLUE SHIELD DC" identifier , issued by the state of ( DC ) . This identifiers is of the category "OTHER".




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