Provider Demographics
NPI:1790982866
Name:MEDX DIAGNOSTIC SERVICE
Entity Type:Organization
Organization Name:MEDX DIAGNOSTIC SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGEER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:F
Authorized Official - Last Name:EGAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-942-1465
Mailing Address - Street 1:4707 140TH AVE N
Mailing Address - Street 2:SUITE 107
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33762-3834
Mailing Address - Country:US
Mailing Address - Phone:727-942-1465
Mailing Address - Fax:
Practice Address - Street 1:4707 140TH AVE N
Practice Address - Street 2:SUITE 107
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33762-3834
Practice Address - Country:US
Practice Address - Phone:727-942-1465
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL5115261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE5286Medicare ID - Type UnspecifiedMEDICARE PROVIDER #