Provider Demographics
NPI:1063564672
Name:BEACHES OPEN MRI, LLC
Entity type:Organization
Organization Name:BEACHES OPEN MRI, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RADIOLOGIST
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:S
Authorized Official - Last Name:FRISK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-247-2220
Mailing Address - Street 1:350 10TH AVE S
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32250-5136
Mailing Address - Country:US
Mailing Address - Phone:904-247-2220
Mailing Address - Fax:904-247-2296
Practice Address - Street 1:350 10TH AVE S
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250-5136
Practice Address - Country:US
Practice Address - Phone:904-247-2220
Practice Address - Fax:904-247-2296
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-17
Last Update Date:2012-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0700012919261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2240835OtherAETNA PROVIDER #
FL38350OtherWELLCARE
FLV2353OtherBCBS PROVIDER #
FLV2353OtherBCBS PROVIDER #
FL=========OtherOTHER
FLG05365Medicare UPIN