Healthcare Provider Details

I. General information

NPI: 1710972419
Provider Name (Legal Business Name): FAYETTEVILLE MRI, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/19/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 MEDICAL CENTER BLVD
FAYETTEVILLE TN
37334-2684
US

IV. Provider business mailing address

4636 LEBANON PIKE PMB 107
HERMITAGE TN
37076-1316
US

V. Phone/Fax

Practice location:
  • Phone: 937-438-7344
  • Fax:
Mailing address:
  • Phone: 931-438-7344
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License NumberNA
License Number StateIN

VIII. Authorized Official

Name: MR. MARK B GABRIEL
Title or Position: PRINCIPAL
Credential:
Phone: 317-634-2222