Provider Demographics
NPI:1720053515
Name:STAND-UP MRI & DIAGNOSTIC CENTER, PA
Entity Type:Organization
Organization Name:STAND-UP MRI & DIAGNOSTIC CENTER, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:LLOYD
Authorized Official - Middle Name:
Authorized Official - Last Name:WAXMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-694-2816
Mailing Address - Street 1:555 W GRANADA BLVD
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-9485
Mailing Address - Country:US
Mailing Address - Phone:386-677-7730
Mailing Address - Fax:386-677-7731
Practice Address - Street 1:555 W GRANADA BLVD
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-9485
Practice Address - Country:US
Practice Address - Phone:386-677-7730
Practice Address - Fax:386-677-7731
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-23
Last Update Date:2008-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL06-186172085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL99229Medicare PIN