Provider Demographics
NPI:1689127201
Name:MIDWAY ULTRASOUND DIAGNOSTIC SERVICES
Entity Type:Organization
Organization Name:MIDWAY ULTRASOUND DIAGNOSTIC SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNET
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:FRANCIS
Authorized Official - Last Name:CROOKS
Authorized Official - Suffix:
Authorized Official - Credentials:RDMS, RVT, RDCS
Authorized Official - Phone:678-994-5407
Mailing Address - Street 1:1801 SE HILLMOOR DR
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-7553
Mailing Address - Country:US
Mailing Address - Phone:678-994-5407
Mailing Address - Fax:
Practice Address - Street 1:1801 SE HILLMOOR DR
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-7553
Practice Address - Country:US
Practice Address - Phone:678-994-5407
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-31
Last Update Date:2016-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD42861261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology