Provider Demographics
NPI:1356309074
Name:FLORIDA DIAGNOSTIC IMAGING CENTER
Entity Type:Organization
Organization Name:FLORIDA DIAGNOSTIC IMAGING CENTER
Other - Org Name:OPEN MRI OF FORT WALTON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:SCHAEFER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-300-0101
Mailing Address - Street 1:PO BOX 933544
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:31193-3544
Mailing Address - Country:US
Mailing Address - Phone:770-300-0101
Mailing Address - Fax:770-300-0429
Practice Address - Street 1:908 MAR WALT DR
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-6706
Practice Address - Country:US
Practice Address - Phone:850-862-9394
Practice Address - Fax:850-862-8533
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-02
Last Update Date:2013-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL262856200Medicaid
FL2403398OtherUNITED HEALTHCARE
FL55303OtherBCBS ALABAMA
FL470000877OtherRR MEDICARE
FLSG076079OtherVISTA SUNRISE
FLV2705OtherBCBS FLORIDA
FL7168661OtherAETNA
FLV2705OtherBCBS FLORIDA
FLV7030Medicare ID - Type UnspecifiedIDTF