Provider Demographics
NPI:1457354318
Name:SHARED PET IMAGING LLC
Entity Type:Organization
Organization Name:SHARED PET IMAGING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SR VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:KASSA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-300-2777
Mailing Address - Street 1:8300 W SUNRISE BLVD
Mailing Address - Street 2:
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33322-5406
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1341 CLARK ST
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:OH
Practice Address - Zip Code:43725
Practice Address - Country:US
Practice Address - Phone:330-491-0480
Practice Address - Fax:330-491-0488
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-24
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0208XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mobile
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2364392Medicaid
OH2651090Medicaid
OH2410251Medicaid
IN200398920Medicaid
CAZZZ01782ZMedicare PIN
IN200398920Medicaid
IN254810Medicare PIN
KY9379401Medicare PIN
OH2651090Medicaid
IN232800Medicare PIN
IN201320Medicare PIN