Organization
FT WALTON OPEN MRI LLC
Active
Other names
Airis Open MRI of Marianna
Organization subpart
No
Provider details
NPI number
Authorized official
MR. KEITH FREUDENBERGER (MANAGER MEMBER)
(850) 862-7070
Entity
Organization
Contact information
Practice address
3015 JEFFERSON ST, SUITE E, MARIANNA, FL 32446-2339
(850) 526-2496
(850) 526-3853
Mailing address
3015 JEFFERSON ST, SUITE E, MARIANNA, FL 32446-2339
(850) 526-2496
(850) 526-3853
Taxonomy
Speciality
Code
Description
License number
State
261QM1200X
Magnetic Resonance Imaging (MRI) Clinic/Center
Primary
HCC4660
FL
261QR0200X
Radiology Clinic/Center
HCC4660
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
7010185
AETNA PROVIDER NO.
FL
01
—
V2838
BCBS FL PROVIDER NO.
FL
Enumeration date
05/18/2006
Last updated
06/17/2008
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