MEDICARE: SOUTHERN OPEN MRI INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	2471C3401X	Computed Tomography Radiologic Technologist
2	2471S1302X	Sonography Radiologic Technologist
3	2471M1202X	Magnetic Resonance Imaging Radiologic Technologist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5259706	OTHER	FL	AETNA PROVIDER NUMBER
2	B796	OTHER	FL	VISTA HEALTH PLAN
3	V2546	OTHER	FL	BLUE CROSS BLUE SHIELD
4	1736853	OTHER	FL	FIRST HEALTH PROVIDER NUM
5	271288	OTHER	FL	AVMED PROVIDER NUMBER

General Provider Information

NPI Number	:	1194795658
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHERN OPEN MRI INC

Provider Business Mailing Address
First Line	:	289 SW STONEGATE TER
Second Line	:	SUITE 102
City	:	LAKE CITY
State	:	FL
Zip	:	32024-3456
Country	:	US
Telephone Number	:	386-755-4788
Fax Number	:	386-755-9980

Provider Business Practice Location Address
First Line	:	289 SW STONEGATE TER
Second Line	:	SUITE 102
City	:	LAKE CITY
State	:	FL
Zip	:	32024-3456
Country	:	US
Telephone Number	:	386-755-4788
Fax Number	:	386-755-9980

Authorized Official
Title or Position	:	VP/CEO/MANAGER
Name	:	MRS. LUCIA M DELAUZ-SAMI
Credential	:	RT(R)
Telephone Number	:	386-755-4788

Provider Enumeration Date	:	01/25/2006
Last Update Date	:	02/19/2008

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Directions to “SOUTHERN OPEN MRI INC ” Practice Location

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