Provider Demographics
NPI:1356939284
Name:DIAGNOSTIC CLINIC MEDICAL GROUP INC
Entity type:Organization
Organization Name:DIAGNOSTIC CLINIC MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:GINA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:PREBECK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-559-9461
Mailing Address - Street 1:7005 4TH ST N
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33702-5909
Mailing Address - Country:US
Mailing Address - Phone:727-501-7300
Mailing Address - Fax:727-501-7360
Practice Address - Street 1:7005 4TH ST N
Practice Address - Street 2:
Practice Address - City:SAINT PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33702-5909
Practice Address - Country:US
Practice Address - Phone:727-501-7300
Practice Address - Fax:727-501-7360
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-06
Last Update Date:2021-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL00036OtherFLORIDA BLUE