Provider Demographics
NPI:1912036781
Name:BREVARD HMA DIAGNOSTIC IMAGING LLC
Entity Type:Organization
Organization Name:BREVARD HMA DIAGNOSTIC IMAGING LLC
Other - Org Name:WUESTHOFF X-RAY AND LAB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR VP AND GENERAL COUNSEL
Authorized Official - Prefix:MR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:PARRY
Authorized Official - Suffix:
Authorized Official - Credentials:ESQ
Authorized Official - Phone:239-598-3131
Mailing Address - Street 1:7970 N WICKHAM RD
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32940-8299
Mailing Address - Country:US
Mailing Address - Phone:321-255-7711
Mailing Address - Fax:321-255-7734
Practice Address - Street 1:7970 N WICKHAM RD
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32940-8299
Practice Address - Country:US
Practice Address - Phone:321-255-7711
Practice Address - Fax:321-255-7734
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-05
Last Update Date:2011-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLHCC35982085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL051814000Medicaid
FL051814000Medicaid