Provider Demographics
NPI:1356331326
Name:MEDICAL DIAGNOSTIC CENTER OF JACKSONVILLE
Entity Type:Organization
Organization Name:MEDICAL DIAGNOSTIC CENTER OF JACKSONVILLE
Other - Org Name:SOUTHBANK IMAGING SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:NICOLAU
Authorized Official - Middle Name:
Authorized Official - Last Name:SACAQUINI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-731-1556
Mailing Address - Street 1:3550 UNIVERSITY BLVD S
Mailing Address - Street 2:STE 102
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-4246
Mailing Address - Country:US
Mailing Address - Phone:904-731-7296
Mailing Address - Fax:904-636-9875
Practice Address - Street 1:3550 UNIVERSITY BLVD S
Practice Address - Street 2:STE 102
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-4246
Practice Address - Country:US
Practice Address - Phone:904-731-7296
Practice Address - Fax:904-636-9875
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE4210Medicare UPIN