Provider Demographics
NPI:1578526919
Name:FAYETTEVILLE MRI LLC
Entity Type:Organization
Organization Name:FAYETTEVILLE MRI LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KERRI
Authorized Official - Middle Name:
Authorized Official - Last Name:COUCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-968-7930
Mailing Address - Street 1:PO BOX 9178
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72811-9178
Mailing Address - Country:US
Mailing Address - Phone:479-968-7930
Mailing Address - Fax:479-968-4331
Practice Address - Street 1:3873 N PARKVIEW DR
Practice Address - Street 2:NO.6
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-6286
Practice Address - Country:US
Practice Address - Phone:800-654-0378
Practice Address - Fax:479-968-4331
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-07
Last Update Date:2009-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR149120002Medicaid
AR5C735OtherBCBS PROVIDER NUMBER
AR5C735Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER