MEDICARE: MRI OF ANDALUSIA 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

General Provider Information

NPI Number	:	1780676601
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MRI OF ANDALUSIA LLC

Provider Business Mailing Address
First Line	:	1823 E THREE NOTCH ST
Second Line	:
City	:	ANDALUSIA
State	:	AL
Zip	:	36421-2403
Country	:	US
Telephone Number	:	334-427-7222
Fax Number	:	334-427-7223

Provider Business Practice Location Address
First Line	:	1823 E THREE NOTCH ST
Second Line	:
City	:	ANDALUSIA
State	:	AL
Zip	:	36421-2403
Country	:	US
Telephone Number	:	334-427-7222
Fax Number	:	334-427-7223

Authorized Official
Title or Position	:	CHIEF OPERATING OFFICER
Name	:	JAMES W. HOLMES
Credential	:
Telephone Number	:	337-291-9161

Provider Enumeration Date	:	08/17/2005
Last Update Date	:	02/13/2008

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