MEDICARE: BEAUFORT 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	261QM1200X	Magnetic Resonance Imaging (MRI) Clinic/Center	14702	SC

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	:	1053375642
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BEAUFORT OPEN MRI, LLC

Provider Business Mailing Address
First Line	:	1319 LADYS ISLAND DR
Second Line	:
City	:	PORT ROYAL
State	:	SC
Zip	:	29935-1153
Country	:	US
Telephone Number	:	843-524-6736
Fax Number	:	843-524-1386

Provider Business Practice Location Address
First Line	:	1319 LADYS ISLAND DR
Second Line	:
City	:	PORT ROYAL
State	:	SC
Zip	:	29935-1153
Country	:	US
Telephone Number	:	843-524-6736
Fax Number	:	843-524-1386

Authorized Official
Title or Position	:	NEUROLOGIST
Name	:	PAUL MAZZEO
Credential	:	M.D.
Telephone Number	:	843-522-1420

Provider Enumeration Date	:	04/12/2006
Last Update Date	:	02/06/2012

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