Provider Demographics
NPI:1215036421
Name:PREMIER DIAGNOSTIC IMAGING SERVICES LLC
Entity Type:Organization
Organization Name:PREMIER DIAGNOSTIC IMAGING SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RAUL
Authorized Official - Middle Name:E
Authorized Official - Last Name:MENESES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-467-4448
Mailing Address - Street 1:3595 W 20TH AVE
Mailing Address - Street 2:SUITE 145
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-4533
Mailing Address - Country:US
Mailing Address - Phone:305-820-1455
Mailing Address - Fax:305-820-1485
Practice Address - Street 1:3595 W 20TH AVE
Practice Address - Street 2:SUITE 145
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-4533
Practice Address - Country:US
Practice Address - Phone:305-820-1455
Practice Address - Fax:305-820-1485
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-22
Last Update Date:2007-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL306480OtherAVMED
FLHCC7443OtherAHCA CLINIC LICENSE
FL58201OtherNEIGHBORHOOD HEALTH PLANS
FLSG 082986OtherVISTA/SUMMIT
FL1057548OtherCARE PLUS
237861OtherFDA CERTIFIED MAMMOGRAPHY
FL375394OtherWELLCARE
FL7027683OtherSUNCOAST HEALTH PLANS
7051871OtherAETNA HEALTH PLANS
FL375394OtherSTAYWELL
FL375394OtherHEALTHEASE
FL5899OtherMEDICA
FL375394OtherHEALTHEASE