Provider Demographics
NPI:1114064888
Name:MIDTOWN DIAGNOSTIC LLC
Entity Type:Organization
Organization Name:MIDTOWN DIAGNOSTIC LLC
Other - Org Name:DBA MIDTOWN RADIOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:LAVELLE
Authorized Official - Middle Name:R
Authorized Official - Last Name:HARDIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-344-8203
Mailing Address - Street 1:1215 EAST AVENUE SOUTH
Mailing Address - Street 2:STE 101
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34239
Mailing Address - Country:US
Mailing Address - Phone:941-365-4565
Mailing Address - Fax:941-955-3284
Practice Address - Street 1:1215 EAST AVENUE SOUTH
Practice Address - Street 2:STE 101
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34239
Practice Address - Country:US
Practice Address - Phone:941-365-4565
Practice Address - Fax:941-955-3284
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-31
Last Update Date:2007-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
No261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)
No261QR0206XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mammography
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAD268Medicare PIN