Provider Demographics
NPI:1164599353
Name:VIDALIA OPEN MRI, LLC
Entity Type:Organization
Organization Name:VIDALIA OPEN MRI, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:FRANK
Authorized Official - Middle Name:
Authorized Official - Last Name:HARRELSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:800-474-1077
Mailing Address - Street 1:3165 E 1ST ST
Mailing Address - Street 2:
Mailing Address - City:VIDALIA
Mailing Address - State:GA
Mailing Address - Zip Code:30474-8830
Mailing Address - Country:US
Mailing Address - Phone:800-474-1077
Mailing Address - Fax:
Practice Address - Street 1:3165 E 1ST ST
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:GA
Practice Address - Zip Code:30474-8830
Practice Address - Country:US
Practice Address - Phone:800-474-1077
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-30
Last Update Date:2007-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0251992471M1202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2471M1202XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistMagnetic Resonance ImagingGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000303751EMedicaid
GA47BBBFSMedicare ID - Type Unspecified