1164676722 NPI number — PLANTATION OPEN MRI, LLC

Table of content: (NPI 1164676722)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164676722 NPI number — PLANTATION OPEN MRI, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PLANTATION 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:
Provider Other Organization Name Type Code:
6
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:
1164676722
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/21/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11011 SHERIDAN ST STE 101
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOLLYWOOD
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33026-1501
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-239-7466
Provider Business Mailing Address Fax Number:
954-200-8725

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4331 N FEDERAL HWY STE 200
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT LAUDERDALE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33308-5252
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-900-2020
Provider Business Practice Location Address Fax Number:
954-343-1855
Provider Enumeration Date:
11/10/2008

Additional Information

Authorized Official

Authorized Official Last Name:
BYERS
Authorized Official First Name:
ANDREW
Authorized Official Middle Name:
MICHAEL
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
954-900-2020

Provider Taxonomy Codes

  • Taxonomy code: 2471M1202X , with the licence number:  39320 , 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: 012245800 . 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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