Provider Demographics
NPI:1922396779
Name:PROFESSIONAL DIAGNOSTIC READING MRI INC.
Entity Type:Organization
Organization Name:PROFESSIONAL DIAGNOSTIC READING MRI INC.
Other - Org Name:ADVANCED MRI DIAGNOSTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:
Authorized Official - Last Name:VIVAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-399-2500
Mailing Address - Street 1:3728 PHILLIPS HWY
Mailing Address - Street 2:STE34
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-9300
Mailing Address - Country:US
Mailing Address - Phone:904-399-2500
Mailing Address - Fax:904-399-2495
Practice Address - Street 1:3728 PHILLIPS HWY
Practice Address - Street 2:STE34
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-9300
Practice Address - Country:US
Practice Address - Phone:904-399-2500
Practice Address - Fax:904-399-2495
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-14
Last Update Date:2013-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1000032322261QM1200X, 261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)
No261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology