Provider Demographics
NPI:1982670022
Name:INSTITUTE OF DIAGNOSTIC IMAGING,LLC
Entity Type:Organization
Organization Name:INSTITUTE OF DIAGNOSTIC IMAGING,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LAURIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BORGSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-314-7575
Mailing Address - Street 1:424 RACETRACK RD NW
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-1556
Mailing Address - Country:US
Mailing Address - Phone:850-314-7575
Mailing Address - Fax:850-314-7494
Practice Address - Street 1:424 RACETRACK RD NW
Practice Address - Street 2:
Practice Address - City:FT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-1556
Practice Address - Country:US
Practice Address - Phone:850-314-7575
Practice Address - Fax:850-314-7494
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-28
Last Update Date:2014-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL6026172085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLDB5733OtherRAILROAD MEDICARE
FL268363600Medicaid
FLDB5733Medicare PIN
FL09981YMedicare PIN
FL268363600Medicaid
FL34904Medicare PIN