MEDICARE: OPEN MRI OF TIFTON 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

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	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1679542526
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OPEN MRI OF TIFTON LLC

Provider Business Mailing Address
First Line	:	PO BOX 4003
Second Line	:
City	:	MACON
State	:	GA
Zip	:	31208-4003
Country	:	US
Telephone Number	:	478-314-5009
Fax Number	:	478-755-9964

Provider Business Practice Location Address
First Line	:	1401 TIFT AVE N STE E
Second Line	:
City	:	TIFTON
State	:	GA
Zip	:	31794-3577
Country	:	US
Telephone Number	:	229-387-6799
Fax Number	:	229-387-6791

Authorized Official
Title or Position	:	DIRECTOR
Name	:	DR. PETER O HOLLIDAY III
Credential	:	MD
Telephone Number	:	478-314-5002

Provider Enumeration Date	:	03/14/2006
Last Update Date	:	05/26/2026

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