1235313057 NPI number — SUGAR MILL DIAGNOSTIC IMAGING LLC

Table of content: (NPI 1235313057)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235313057 NPI number — SUGAR MILL DIAGNOSTIC IMAGING LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUGAR MILL DIAGNOSTIC IMAGING LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1235313057
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/31/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8303 S SUNCOAST BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOMOSASSA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34446-5028
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
352-628-9900
Provider Business Mailing Address Fax Number:
352-628-9700

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8303 S SUNCOAST BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOMOSASSA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34446-5028
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-628-9900
Provider Business Practice Location Address Fax Number:
352-628-9700
Provider Enumeration Date:
12/28/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HERRON
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
KEITH
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
352-795-6909

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X , with the licence number:  N/A , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QR0200X , with the licence number: ME84779 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: V3279 . This is a "BLUE CROSS BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000097001 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: DN9284 . This is a "RR MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: V003E . This is a "BLUE CROSS BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000097000 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 002077400 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: DN9284 . This is a "RR MEDICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 000097000 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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