Provider Demographics
NPI:1194145714
Name:MARSHALL COUNTY MRI, LLC
Entity type:Organization
Organization Name:MARSHALL COUNTY MRI, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:G
Authorized Official - Last Name:FUQUA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-527-4850
Mailing Address - Street 1:615 OLD SYMSONIA RD
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:KY
Mailing Address - Zip Code:42025-5042
Mailing Address - Country:US
Mailing Address - Phone:270-527-4850
Mailing Address - Fax:
Practice Address - Street 1:615 OLD SYMSONIA RD
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:KY
Practice Address - Zip Code:42025-5042
Practice Address - Country:US
Practice Address - Phone:270-527-4850
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-22
Last Update Date:2014-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)