Healthcare Provider Details

I. General information

NPI: 1053375642
Provider Name (Legal Business Name): BEAUFORT OPEN MRI, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2006
Last Update Date: 02/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1319 LADYS ISLAND DR
PORT ROYAL SC
29935-1153
US

IV. Provider business mailing address

1319 LADYS ISLAND DR
PORT ROYAL SC
29935-1153
US

V. Phone/Fax

Practice location:
  • Phone: 843-524-6736
  • Fax: 843-524-1386
Mailing address:
  • Phone: 843-524-6736
  • Fax: 843-524-1386

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1200X
TaxonomyMagnetic Resonance Imaging (MRI) Clinic/Center
License Number14702
License Number StateSC

VIII. Authorized Official

Name: PAUL MAZZEO
Title or Position: NEUROLOGIST
Credential: M.D.
Phone: 843-522-1420