1396825741 NPI number — OPEN MRI OF DOUGLAS LLC

Table of content: (NPI 1396825741)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396825741 NPI number — OPEN MRI OF DOUGLAS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OPEN MRI OF DOUGLAS 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:
1396825741
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/27/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1103 FOUNTAIN LAKE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRUNSWICK
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31525-3039
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
912-267-6736
Provider Business Mailing Address Fax Number:
912-262-1922

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1315 OCILLA ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DOUGLAS
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31533
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
912-393-1144
Provider Business Practice Location Address Fax Number:
912-393-1124
Provider Enumeration Date:
10/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HARRIS
Authorized Official First Name:
CAROLINE
Authorized Official Middle Name:
Authorized Official Title or Position:
ACCOUNT DIRECTOR
Authorized Official Telephone Number:
912-267-6736

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1942294848 . This is a "RADIOLOGIST" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 00469169H , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com