Healthcare Provider Details

I. General information

NPI: 1730145988
Provider Name (Legal Business Name): FORT PAYNE MRI LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2006
Last Update Date: 02/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1110 GLENN BLVD SW SUITE 100
FORT PAYNE AL
35967-8486
US

IV. Provider business mailing address

1110 GLENN BLVD SW SUITE 100
FORT PAYNE AL
35967-8486
US

V. Phone/Fax

Practice location:
  • Phone: 256-845-9402
  • Fax: 256-845-9410
Mailing address:
  • Phone: 256-845-9402
  • Fax: 256-845-9410

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: JAMES W. HOLMES
Title or Position: CHIEF OPERATING OFFICER
Credential:
Phone: 337-291-9161