Provider Demographics
NPI:1043631914
Name:EXPRESS RADIOLOGY GROUP, INC.
Entity Type:Organization
Organization Name:EXPRESS RADIOLOGY GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:P.D
Authorized Official - Prefix:
Authorized Official - First Name:FERNAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BLANCO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-252-5023
Mailing Address - Street 1:175 FONTAINEBLEAU BLVD
Mailing Address - Street 2:SUITE 2 G1
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33172-7018
Mailing Address - Country:US
Mailing Address - Phone:305-603-9983
Mailing Address - Fax:
Practice Address - Street 1:175 FONTAINEBLEAU BLVD
Practice Address - Street 2:SUITE 2 G1
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33172-7018
Practice Address - Country:US
Practice Address - Phone:305-603-9983
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-19
Last Update Date:2014-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLBMO59003261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiologyGroup - Multi-Specialty