Provider Demographics
NPI:1790746956
Name:EDMOND MRI LLC
Entity Type:Organization
Organization Name:EDMOND MRI LLC
Other - Org Name:RENAISSANCE MRI
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:
Authorized Official - Last Name:MALONE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-321-8125
Mailing Address - Street 1:1705 RENAISSANCE BLVD
Mailing Address - Street 2:SUITE 135
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-3022
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1705 RENAISSANCE BLVD
Practice Address - Street 2:SUITE 135
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-3022
Practice Address - Country:US
Practice Address - Phone:580-234-2878
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
=========Medicare ID - Type Unspecified