1578210886 NPI number — FLORIDA DIAGNOSTIC IMAGING CENTER INC

Table of content: (NPI 1578210886)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578210886 NPI number — FLORIDA DIAGNOSTIC IMAGING CENTER INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FLORIDA DIAGNOSTIC IMAGING CENTER INC
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:
1578210886
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3024 BUSINESS PARK CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GOODLETTSVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37072-3132
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-854-3409
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2525 MARTIN LUTHER KING JR BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PANAMA CITY
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32405-4414
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-873-6900
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/07/2022

Additional Information

Authorized Official

Authorized Official Last Name:
FENTON
Authorized Official First Name:
SUSAN
Authorized Official Middle Name:
Authorized Official Title or Position:
CREDENTIALING DIRECTOR
Authorized Official Telephone Number:
615-854-3409

Provider Taxonomy Codes

  • Taxonomy code: 261QR0208X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com