=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003308040
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TITAN MRI LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/05/2018
-----------------------------------------------------
Last Update Date | 06/27/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 919 NW 57TH ST STE 20
-----------------------------------------------------
City | GAINESVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32605
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-672-6644
-----------------------------------------------------
Fax | 352-672-2103
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 919 NW 57TH ST STE 20
-----------------------------------------------------
City | GAINESVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32605-6416
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-672-6644
-----------------------------------------------------
Fax | 352-672-2103
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING MEMBER
-----------------------------------------------------
Name | DAVID BURNS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 904-868-3630
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM1200X
-----------------------------------------------------
Taxonomy Name | Magnetic Resonance Imaging (MRI) Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------