Provider Demographics
NPI:1740283639
Name:NATIONAL PET SCAN DUVAL, LLC
Entity type:Organization
Organization Name:NATIONAL PET SCAN DUVAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROJECT MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-358-8441
Mailing Address - Street 1:1 INDEPENDENT DR
Mailing Address - Street 2:STE 2201
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32202-5015
Mailing Address - Country:US
Mailing Address - Phone:904-358-8441
Mailing Address - Fax:904-358-2288
Practice Address - Street 1:425 N LEE ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-1127
Practice Address - Country:US
Practice Address - Phone:904-861-6000
Practice Address - Fax:904-861-6007
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-24
Last Update Date:2012-02-27
Deactivation Date:2011-07-26
Deactivation Code:
Reactivation Date:2012-02-27
Provider Licenses
StateLicense IDTaxonomies
FLHCC5690261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL7051350OtherAETNA NON HMO
FLV2569OtherBLUE CROSS BLUE SHIELD FL
FL3190985OtherAETNA HMO
FL1730079-001OtherCIGNA
FL593688943OtherHUMANA
FL201709OtherWELLCARE
FL593688943OtherTRICARE
FLE7348Medicare ID - Type UnspecifiedMEDICARE PROVIDER ID
FLCK2449Medicare ID - Type UnspecifiedMEDICARE RAILROAD RETIREM