Provider Demographics
NPI:1194795658
Name:SOUTHERN OPEN MRI INC
Entity type:Organization
Organization Name:SOUTHERN OPEN MRI INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP/CEO/MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LUCIA
Authorized Official - Middle Name:M
Authorized Official - Last Name:DELAUZ-SAMI
Authorized Official - Suffix:
Authorized Official - Credentials:RT(R)
Authorized Official - Phone:386-755-4788
Mailing Address - Street 1:289 SW STONEGATE TER
Mailing Address - Street 2:SUITE 102
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32024-3456
Mailing Address - Country:US
Mailing Address - Phone:386-755-4788
Mailing Address - Fax:386-755-9980
Practice Address - Street 1:289 SW STONEGATE TER
Practice Address - Street 2:SUITE 102
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32024-3456
Practice Address - Country:US
Practice Address - Phone:386-755-4788
Practice Address - Fax:386-755-9980
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-25
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2471M1202XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistMagnetic Resonance ImagingGroup - Multi-Specialty
No2471C3401XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistComputed TomographyGroup - Multi-Specialty
No2471S1302XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistSonographyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL5259706OtherAETNA PROVIDER NUMBER
FLB796OtherVISTA HEALTH PLAN
FLV2546OtherBLUE CROSS BLUE SHIELD
FL1736853OtherFIRST HEALTH PROVIDER NUM
FL271288OtherAVMED PROVIDER NUMBER
FL5259706OtherAETNA PROVIDER NUMBER