Provider Demographics
NPI:1235313057
Name:SUGAR MILL DIAGNOSTIC IMAGING LLC
Entity Type:Organization
Organization Name:SUGAR MILL DIAGNOSTIC IMAGING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:KEITH
Authorized Official - Last Name:HERRON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-795-6909
Mailing Address - Street 1:8303 S SUNCOAST BLVD
Mailing Address - Street 2:
Mailing Address - City:HOMOSASSA
Mailing Address - State:FL
Mailing Address - Zip Code:34446-5028
Mailing Address - Country:US
Mailing Address - Phone:352-628-9900
Mailing Address - Fax:352-628-9700
Practice Address - Street 1:8303 S SUNCOAST BLVD
Practice Address - Street 2:
Practice Address - City:HOMOSASSA
Practice Address - State:FL
Practice Address - Zip Code:34446-5028
Practice Address - Country:US
Practice Address - Phone:352-628-9900
Practice Address - Fax:352-628-9700
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-28
Last Update Date:2013-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLN/A2085R0202X
FLME84779261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
No261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
V3279OtherBLUE CROSS BLUE SHIELD
FL000097001Medicaid
DN9284OtherRR MEDICARE
V003EOtherBLUE CROSS BLUE SHIELD
FL000097000Medicaid
FL002077400Medicaid
FLDN9284OtherRR MEDICARE
FLDN9284OtherRR MEDICARE