MEDICARE: OPEN MRI, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2085R0202X	Diagnostic Radiology Physician		MS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1801892831
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OPEN MRI, LLC

Provider Business Mailing Address
First Line	:	PO BOX 789
Second Line	:
City	:	OCEAN SPRINGS
State	:	MS
Zip	:	39566-0789
Country	:	US
Telephone Number	:	228-818-0563
Fax Number	:	228-818-0519

Provider Business Practice Location Address
First Line	:	1720C MEDICAL PARK DR
Second Line	:
City	:	BILOXI
State	:	MS
Zip	:	39532-2131
Country	:	US
Telephone Number	:	228-354-0251
Fax Number	:	228-396-3550

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MR. RANDALL PENBERG
Credential	:
Telephone Number	:	228-818-0563

Provider Enumeration Date	:	06/23/2005
Last Update Date	:	08/22/2020

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