Provider Demographics
NPI:1639204142
Name:OPEN MRI OF LAGRANGE LLC
Entity Type:Organization
Organization Name:OPEN MRI OF LAGRANGE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:RANDOLPH
Authorized Official - Last Name:COMERFORD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-882-1399
Mailing Address - Street 1:1805 VERNON RD
Mailing Address - Street 2:SUITE D
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30240-4041
Mailing Address - Country:US
Mailing Address - Phone:706-882-1399
Mailing Address - Fax:706-882-1421
Practice Address - Street 1:1805 VERNON RD
Practice Address - Street 2:SUITE D
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240-4041
Practice Address - Country:US
Practice Address - Phone:706-882-1399
Practice Address - Fax:706-882-1421
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes293D00000XLaboratoriesPhysiological Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00599189BMedicaid
GAY01910Medicare UPIN
GA47BBBKHMedicare ID - Type Unspecified