1356309074 NPI number — FLORIDA DIAGNOSTIC IMAGING CENTER

Table of content: (NPI 1356309074)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356309074 NPI number — FLORIDA DIAGNOSTIC IMAGING CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FLORIDA DIAGNOSTIC IMAGING CENTER
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:
OPEN MRI OF FORT WALTON
Provider Other Organization Name Type Code:
3
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:
1356309074
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/23/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 933544
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31193-3544
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-300-0101
Provider Business Mailing Address Fax Number:
770-300-0429

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
908 MAR WALT DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT WALTON BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32547-6706
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-862-9394
Provider Business Practice Location Address Fax Number:
850-862-8533
Provider Enumeration Date:
05/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SCHAEFER
Authorized Official First Name:
DANIEL
Authorized Official Middle Name:
J
Authorized Official Title or Position:
COO
Authorized Official Telephone Number:
770-300-0101

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 262856200 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2403398 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 55303 . This is a "BCBS ALABAMA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 470000877 . This is a "RR MEDICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: SG076079 . This is a "VISTA SUNRISE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: V2705 . This is a "BCBS FLORIDA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 7168661 . This is a "AETNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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