Provider Demographics
NPI:1801892831
Name:OPEN MRI, LLC
Entity type:Organization
Organization Name:OPEN MRI, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:
Authorized Official - Last Name:PENBERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:228-818-0563
Mailing Address - Street 1:PO BOX 789
Mailing Address - Street 2:
Mailing Address - City:OCEAN SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39566-0789
Mailing Address - Country:US
Mailing Address - Phone:228-818-0563
Mailing Address - Fax:228-818-0519
Practice Address - Street 1:1720C MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39532-2131
Practice Address - Country:US
Practice Address - Phone:228-354-0251
Practice Address - Fax:228-396-3550
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08882814Medicaid