MEDICARE: ATLANTIC 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	261QR0200X	Radiology Clinic/Center	22368	NJ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2K6430	OTHER	NJ	HEALTHNET PIN#
2	1839680	OTHER	NJ	UNITEDHEALTHCARE PIN#
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	1130240V	OTHER	NJ	NJ HORIZON MERCY PIN#
5	2098369000	OTHER	NJ	AMERIHEALTH PIN#
6	4103497	OTHER	NJ	GHI PIN#
7	28090922	OTHER	NJ	AETNA PIN#
8	A959624	OTHER	NJ	OXFORD PIN#

General Provider Information

NPI Number	:	1700942208
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ATLANTIC OPEN MRI, LLC

Provider Business Mailing Address
First Line	:	766 SHREWSBURY AVE
Second Line	:
City	:	TINTON FALLS
State	:	NJ
Zip	:	07724-3001
Country	:	US
Telephone Number	:	732-530-8989
Fax Number	:	732-530-0420

Provider Business Practice Location Address
First Line	:	766 SHREWSBURY AVE
Second Line	:
City	:	TINTON FALLS
State	:	NJ
Zip	:	07724-3001
Country	:	US
Telephone Number	:	732-530-8989
Fax Number	:	732-530-0420

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	DR. DOUGLAS T GIBBENS
Credential	:	M.D.
Telephone Number	:	732-530-8989

Provider Enumeration Date	:	12/29/2006
Last Update Date	:	02/28/2008

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