Provider Demographics
NPI:1972872604
Name:MANATEE DIAGNOSTIC CENTER WEST
Entity Type:Organization
Organization Name:MANATEE DIAGNOSTIC CENTER WEST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DAVIS
Authorized Official - Middle Name:W
Authorized Official - Last Name:GRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:941-747-3034
Mailing Address - Street 1:2211 60TH ST WEST
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34209
Mailing Address - Country:US
Mailing Address - Phone:941-747-3034
Mailing Address - Fax:941-748-5819
Practice Address - Street 1:2211 60TH ST WEST
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34209
Practice Address - Country:US
Practice Address - Phone:941-747-3034
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MANATEE DIAGNOSTIC CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-12-27
Last Update Date:2011-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME65402085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL48245500Medicaid
FL48245500Medicaid