Provider Demographics
NPI:1376650820
Name:FAIRWAY IMAGING, LLC
Entity Type:Organization
Organization Name:FAIRWAY IMAGING, LLC
Other - Org Name:PREMIER MRI 4 U
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MONICA
Authorized Official - Middle Name:
Authorized Official - Last Name:RESTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:985-809-6744
Mailing Address - Street 1:1200 PINNACLE PARKWAY
Mailing Address - Street 2:SUITE 5
Mailing Address - City:COVINGTON
Mailing Address - State:LA
Mailing Address - Zip Code:70433-9169
Mailing Address - Country:US
Mailing Address - Phone:985-809-6744
Mailing Address - Fax:985-809-6745
Practice Address - Street 1:1200 PINNACLE PARKWAY
Practice Address - Street 2:SUITE 5
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433-9169
Practice Address - Country:US
Practice Address - Phone:985-809-6744
Practice Address - Fax:965-809-6745
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-23
Last Update Date:2016-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes293D00000XLaboratoriesPhysiological LaboratoryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5 CK 75Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER