Provider Demographics
NPI:1336187830
Name:FLORIDA DIAGNOSTIC IMAGING CENTER INC
Entity Type:Organization
Organization Name:FLORIDA DIAGNOSTIC IMAGING CENTER INC
Other - Org Name:FLORIDA MOBILE MRI - PACE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:SCHAEFER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-300-0101
Mailing Address - Street 1:3480 PRESTON RIDGE RD STE 600
Mailing Address - Street 2:CREDENTIALING DEPT
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30005-5462
Mailing Address - Country:US
Mailing Address - Phone:770-300-0101
Mailing Address - Fax:770-300-0429
Practice Address - Street 1:4494 HIGHWAY 90
Practice Address - Street 2:
Practice Address - City:PACE
Practice Address - State:FL
Practice Address - Zip Code:32571-2061
Practice Address - Country:US
Practice Address - Phone:850-484-8454
Practice Address - Fax:850-484-7754
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-04
Last Update Date:2007-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE7031Medicare ID - Type UnspecifiedIDTF