Provider Demographics
NPI:1629194923
Name:FLORIDA EAST COAST IMAGING LLC
Entity Type:Organization
Organization Name:FLORIDA EAST COAST IMAGING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:FLYNN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-793-9300
Mailing Address - Street 1:PO BOX 15659
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33766-5659
Mailing Address - Country:US
Mailing Address - Phone:727-793-9300
Mailing Address - Fax:
Practice Address - Street 1:5005 PORT ST JOHN PKWY
Practice Address - Street 2:
Practice Address - City:PORT ST JOHN
Practice Address - State:FL
Practice Address - Zip Code:32927-4305
Practice Address - Country:US
Practice Address - Phone:321-636-9393
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL278373800Medicaid
FLDH0129OtherRR MCR
FL278373800Medicaid