Basic Information
| Provider Information | |||||||||
| NPI: | 1154784205 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MED VENTURES MRI, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1975 HWY 54 W. | ||||||||
| Address2: | STE 205 | ||||||||
| City: | PEACHTREE CITY | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302694794 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6785619000 | ||||||||
| FaxNumber: | 7704871232 | ||||||||
| Practice Location | |||||||||
| Address1: | 1075 LAFAYETTE PARKWAY | ||||||||
| Address2: | STE 120 | ||||||||
| City: | LAGRANGE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30241 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7068459370 | ||||||||
| FaxNumber: | 7068459371 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/05/2016 | ||||||||
| LastUpdateDate: | 04/05/2016 | ||||||||
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| AuthorizedOfficialLastName: | HOLLSTROM | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
| AuthorizedOfficialMiddleName: | P. | ||||||||
| AuthorizedOfficialTitleorPosition: | AUTHORIZED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 7065940687 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | DPM | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | GA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.