Provider Demographics
NPI:1710200845
Name:PARTNERS IMAGING CENTER OF CHARLOTTE LLC
Entity Type:Organization
Organization Name:PARTNERS IMAGING CENTER OF CHARLOTTE LLC
Other - Org Name:PARTNERS IMAGING CENTER OF PORT CHARLOTTE
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:MITCHELL
Authorized Official - Middle Name:
Authorized Official - Last Name:GEISLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:647-288-1508
Mailing Address - Street 1:848 N RAINBOW BLVD STE 2494
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89107-1103
Mailing Address - Country:US
Mailing Address - Phone:877-700-1093
Mailing Address - Fax:877-484-5173
Practice Address - Street 1:4161 TAMIAMI TRL STE 204
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-9204
Practice Address - Country:US
Practice Address - Phone:941-255-5151
Practice Address - Fax:941-255-5152
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-03
Last Update Date:2017-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLHCC10461261QM1200X, 261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)
No261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLFL114AMedicare PIN