1194728014 NPI number — NATIONAL P E T SCAN BROWARD LLC

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194728014 NPI number — NATIONAL P E T SCAN BROWARD LLC

Employer Identification Number (EIN):

Provider Organization Name:

NATIONAL P E T SCAN BROWARD 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 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:

1194728014

Entity Type Code:

Organization

Replacement NPI:

Last Update Date:

12/05/2012

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

6622 SOUTHPOINT DR S

Provider Second Line Business Mailing Address:

SUITE 360

Provider Business Mailing Address City Name:

JACKSONVILLE

Provider Business Mailing Address State Name:

FL

Provider Business Mailing Address Postal Code:

32216-8014

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

904-358-8441

Provider Business Mailing Address Fax Number:

904-358-2288

Provider First Line Business Practice Location Address:

6290 N FEDERAL HWY

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:

FT LAUDERDALE

Provider Business Practice Location Address State Name:

FL

Provider Business Practice Location Address Postal Code:

33308-1917

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

954-332-3000

Provider Business Practice Location Address Fax Number:

954-332-2671

Provider Enumeration Date:

05/24/2005

Authorized Official Last Name:

AUSTIN

Authorized Official First Name:

MARGIE

Authorized Official Middle Name:

FAYE

Authorized Official Title or Position:

ADMINISTRATIVE ASSISTANT

Authorized Official Telephone Number:

904-358-8441

• Taxonomy code: 261QR0200X , with the licence number:  HCC5688 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 196704 . This is a "WELLCARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
• Identifier: 2630670 . This is a "AETNA - HMO" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
• Identifier: 593688943 . This is a "TRICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
• Identifier: CK2451 . This is a "MEDICARE RAILROAD RETIREM" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
• Identifier: 38830 . This is a "NEIGHBORHOOD" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
• Identifier: 67826 . This is a "FOUNDATION" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
• Identifier: V2274 . This is a "BLUE CROSS BLUE SHIELD FL" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
• Identifier: 593688943 . This is a "HUMANA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
• Identifier: SG011169 . This is a "VISTA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
• Identifier: 6958176-001 . This is a "CIGNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
• Identifier: 7441285 . This is a "AETNA - PPO" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".