Provider Demographics
NPI:1093087124
Name:INNOVATIVE OPEN MRI OF PENSACOLA LLC
Entity Type:Organization
Organization Name:INNOVATIVE OPEN MRI OF PENSACOLA LLC
Other - Org Name:STAND UP OPEN MRI OF PENSACOLA LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER,PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:AARON
Authorized Official - Middle Name:BRYANT
Authorized Official - Last Name:MONTGOMERY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-433-0674
Mailing Address - Street 1:890 S. PALAFOX STREET
Mailing Address - Street 2:SUITE 110
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32524-5905
Mailing Address - Country:US
Mailing Address - Phone:850-433-0674
Mailing Address - Fax:850-433-5965
Practice Address - Street 1:890 S. PALAFOX STREET
Practice Address - Street 2:SUITE 110
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32524-5905
Practice Address - Country:US
Practice Address - Phone:850-433-0674
Practice Address - Fax:850-433-5965
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-06
Last Update Date:2015-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QM1200X
FL261QM1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLHA732AMedicare PIN