Provider Demographics
NPI:1972740884
Name:OPEN MRI OF BRUNSWICK LLC
Entity type:Organization
Organization Name:OPEN MRI OF BRUNSWICK LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:K
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-451-4040
Mailing Address - Street 1:2414B PARKWOOD DR
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:GA
Mailing Address - Zip Code:31520-4721
Mailing Address - Country:US
Mailing Address - Phone:770-451-4040
Mailing Address - Fax:770-451-3003
Practice Address - Street 1:2414 PARKWOOD DR
Practice Address - Street 2:SUITE 100
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31520-4779
Practice Address - Country:US
Practice Address - Phone:770-451-4040
Practice Address - Fax:770-451-3003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-14
Last Update Date:2012-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0314322471M1202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2471M1202XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistMagnetic Resonance ImagingGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA202I300099OtherMEDICARE PROVIDER
GA000449765ACMedicaid
GA202I300099OtherMEDICARE PROVIDER
GA000449765ACMedicaid