Provider Demographics
NPI:1992757678
Name:FT WALTON OPEN MRI LLC
Entity type:Organization
Organization Name:FT WALTON OPEN MRI LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:
Authorized Official - Last Name:FREUDENBERGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-862-7070
Mailing Address - Street 1:1112 HOSPITAL RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-6742
Mailing Address - Country:US
Mailing Address - Phone:850-862-7070
Mailing Address - Fax:850-862-0900
Practice Address - Street 1:1112 HOSPITAL RD
Practice Address - Street 2:SUITE B
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-6742
Practice Address - Country:US
Practice Address - Phone:850-862-7070
Practice Address - Fax:850-862-0900
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-17
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLHCC4491261QM1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLV2836OtherBCBS FL PROVIDER NO.
FL7010185OtherAETNA PROVIDER NO.
FLV2836OtherBCBS FL PROVIDER NO.