Provider Demographics
NPI:1043676034
Name:DIAGNOSTIC CLINIC MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:DIAGNOSTIC CLINIC MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:GINA
Authorized Official - Middle Name:M
Authorized Official - Last Name:PREBECK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:727-581-8767
Mailing Address - Street 1:1301 2ND AVE SW
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33770-3120
Mailing Address - Country:US
Mailing Address - Phone:727-581-8767
Mailing Address - Fax:727-581-8507
Practice Address - Street 1:1301 2ND AVE SW
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33770-3120
Practice Address - Country:US
Practice Address - Phone:727-581-8767
Practice Address - Fax:727-581-8507
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-07
Last Update Date:2020-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLV00EYOtherFLORIDA BLUE