MEDICARE: OPEN MRI OF LAKE HAVASU 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	2085R0202X	Diagnostic Radiology Physician	OTC3930	AZ

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
4	P00308294	OTHER	AL	MEDICARE RR PALMETTO GBA

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
2	OTC3930	OTHER	AZ	AZ DEPT OF HEALTH SVC
3	AZ0155710	OTHER	AZ	BLUE CROSS

General Provider Information

NPI Number	:	1669438867
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OPEN MRI OF LAKE HAVASU LLC

Provider Business Mailing Address
First Line	:	604B MADISON ST SE
Second Line	:
City	:	HUNTSVILLE
State	:	AL
Zip	:	35801-4401
Country	:	US
Telephone Number	:	256-533-2311
Fax Number	:	256-533-2231

Provider Business Practice Location Address
First Line	:	2082 MESQUITE AVE
Second Line	:	SUITE 114
City	:	LAKE HAVASU CITY
State	:	AZ
Zip	:	86403-6717
Country	:	US
Telephone Number	:	928-505-1511
Fax Number	:	928-505-1541

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	TOMMY R HARRIS
Credential	:
Telephone Number	:	256-990-2629

Provider Enumeration Date	:	04/25/2006
Last Update Date	:	02/22/2008

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