Provider Demographics
NPI:1730288515
Name:SHARPER IMAGING DIAGNOSTIC RADIOLOGY CENTER INC
Entity Type:Organization
Organization Name:SHARPER IMAGING DIAGNOSTIC RADIOLOGY CENTER INC
Other - Org Name:HARBOR IMAGING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:BLACKMER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:941-276-3517
Mailing Address - Street 1:3430 TAMIAMI TRL
Mailing Address - Street 2:SUITE B
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33952-8127
Mailing Address - Country:US
Mailing Address - Phone:941-883-8383
Mailing Address - Fax:941-883-8386
Practice Address - Street 1:3430 TAMIAMI TRL
Practice Address - Street 2:SUITE B
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-8127
Practice Address - Country:US
Practice Address - Phone:941-883-8383
Practice Address - Fax:941-883-8386
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME67871261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
150492200863OtherHUMANA
V2822OtherBCBS
213119OtherAMERIGROUP
=========OtherUNITED HEALTHCARE
150492200863OtherHUMANA
150492200863OtherHUMANA