Provider Demographics
NPI:1225069891
Name:ADVANTAGE OPEN MRI OF TAMPA
Entity Type:Organization
Organization Name:ADVANTAGE OPEN MRI OF TAMPA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-939-2674
Mailing Address - Street 1:101 E KENNEDY BLVD
Mailing Address - Street 2:SUITE 2350
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33602-5179
Mailing Address - Country:US
Mailing Address - Phone:813-463-4441
Mailing Address - Fax:813-849-6349
Practice Address - Street 1:3104 W WATERS AVE
Practice Address - Street 2:#14
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33634
Practice Address - Country:US
Practice Address - Phone:813-935-5332
Practice Address - Fax:813-933-5849
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-05
Last Update Date:2008-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL8176261QM1200X
FLHCC6139261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)
No261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
U4395Medicare ID - Type Unspecified