Provider Demographics
NPI:1750353629
Name:FLORIDA DIAGNOSTIC IMAGING CENTER
Entity type:Organization
Organization Name:FLORIDA DIAGNOSTIC IMAGING CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
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 1:2457 CARE DR
Practice Address - Street 2:SUITE D-100
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-4580
Practice Address - Country:US
Practice Address - Phone:850-671-7260
Practice Address - Fax:850-671-7265
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-06
Last Update Date:2008-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU0727Medicare ID - Type Unspecified