1215036421 NPI number — PREMIER DIAGNOSTIC IMAGING SERVICES LLC

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215036421 NPI number — PREMIER DIAGNOSTIC IMAGING SERVICES LLC

Employer Identification Number (EIN):

Provider Organization Name:

PREMIER DIAGNOSTIC IMAGING SERVICES 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:

1215036421

Entity Type Code:

Organization

Replacement NPI:

Last Update Date:

10/07/2007

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

3595 W 20TH AVE

Provider Second Line Business Mailing Address:

SUITE 145

Provider Business Mailing Address City Name:

HIALEAH

Provider Business Mailing Address State Name:

FL

Provider Business Mailing Address Postal Code:

33012-4533

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

305-820-1455

Provider Business Mailing Address Fax Number:

305-820-1485

Provider First Line Business Practice Location Address:

3595 W 20TH AVE

Provider Second Line Business Practice Location Address:

SUITE 145

Provider Business Practice Location Address City Name:

HIALEAH

Provider Business Practice Location Address State Name:

FL

Provider Business Practice Location Address Postal Code:

33012-4533

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

305-820-1455

Provider Business Practice Location Address Fax Number:

305-820-1485

Provider Enumeration Date:

09/22/2006

Authorized Official Last Name:

MENESES

Authorized Official First Name:

RAUL

Authorized Official Middle Name:

E

Authorized Official Title or Position:

PRESIDENT

Authorized Official Telephone Number:

305-467-4448

• Taxonomy code: 261QR0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 306480 . This is a "AVMED" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
• Identifier: HCC7443 . This is a "AHCA CLINIC LICENSE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
• Identifier: 58201 . This is a "NEIGHBORHOOD HEALTH PLANS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
• Identifier: SG 082986 . This is a "VISTA/SUMMIT" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
• Identifier: 1057548 . This is a "CARE PLUS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
• Identifier: 237861 . This is a "FDA CERTIFIED MAMMOGRAPHY" identifier . This identifiers is of the category "OTHER".
• Identifier: 375394 . This is a "WELLCARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
• Identifier: 7027683 . This is a "SUNCOAST HEALTH PLANS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
• Identifier: 7051871 . This is a "AETNA HEALTH PLANS" identifier . This identifiers is of the category "OTHER".
• Identifier: 375394 . This is a "STAYWELL" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
• Identifier: 375394 . This is a "HEALTHEASE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
• Identifier: 5899 . This is a "MEDICA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".