Provider Demographics
NPI:1700942208
Name:ATLANTIC OPEN MRI, LLC
Entity Type:Organization
Organization Name:ATLANTIC OPEN MRI, LLC
Other - Org Name:ATLANTIC DIAGNOSTICS, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:T
Authorized Official - Last Name:GIBBENS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:732-530-8989
Mailing Address - Street 1:766 SHREWSBURY AVE
Mailing Address - Street 2:
Mailing Address - City:TINTON FALLS
Mailing Address - State:NJ
Mailing Address - Zip Code:07724-3001
Mailing Address - Country:US
Mailing Address - Phone:732-530-8989
Mailing Address - Fax:732-530-0420
Practice Address - Street 1:766 SHREWSBURY AVE
Practice Address - Street 2:
Practice Address - City:TINTON FALLS
Practice Address - State:NJ
Practice Address - Zip Code:07724-3001
Practice Address - Country:US
Practice Address - Phone:732-530-8989
Practice Address - Fax:732-530-0420
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-29
Last Update Date:2008-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22368261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2K6430OtherHEALTHNET PIN#
NJ1839680OtherUNITEDHEALTHCARE PIN#
NJ8211302Medicaid
NJ1130240VOtherNJ HORIZON MERCY PIN#
NJ2098369000OtherAMERIHEALTH PIN#
NJ4103497OtherGHI PIN#
NJ28090922OtherAETNA PIN#
NJA959624OtherOXFORD PIN#
NJ4103497OtherGHI PIN#