Provider Demographics
NPI:1255438974
Name:SOUTHEAST GEORGIA OPEN MRI LLC
Entity type:Organization
Organization Name:SOUTHEAST GEORGIA OPEN MRI LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACCOUNT DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:CAROLINE
Authorized Official - Middle Name:
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-267-6736
Mailing Address - Street 1:1103 FOUNTAIN LAKE DRIVE
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:GA
Mailing Address - Zip Code:31525
Mailing Address - Country:US
Mailing Address - Phone:912-267-6736
Mailing Address - Fax:912-262-1922
Practice Address - Street 1:1103 FOUNTAIN LAKE DRIVE
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31525
Practice Address - Country:US
Practice Address - Phone:912-267-6736
Practice Address - Fax:912-262-1922
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-17
Last Update Date:2012-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00469169GMedicaid
1942294848OtherBILLING PROVIDER NUMBER
GA300091187Medicare UPIN
GA00469169GMedicaid