1134188824 NPI number — SUNCOAST OPEN MRI LLC

Table of content: (NPI 1134188824)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134188824 NPI number — SUNCOAST OPEN MRI LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUNCOAST OPEN MRI 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:
SUNCOAST DIAGNOSTIC IMAGING
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:
1134188824
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/28/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 4003
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MACON
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31208
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
478-755-9966
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
511 E 23RD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PANAMA CITY
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32405-5307
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-747-8822
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HOLLIDAY
Authorized Official First Name:
PETER
Authorized Official Middle Name:
O
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
478-474-2360

Provider Taxonomy Codes

  • Taxonomy code: 261QM1200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QR0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: V2722 . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 274676000 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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