Provider Demographics
NPI:1780110411
Name:MEDICAL DIAGNOSTIC PROFESSIONAL MANAGEMENT
Entity type:Organization
Organization Name:MEDICAL DIAGNOSTIC PROFESSIONAL MANAGEMENT
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGEMENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:MOTHERSIL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-440-0998
Mailing Address - Street 1:8380 BAYMEADOWS RD STE 17
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-7435
Mailing Address - Country:US
Mailing Address - Phone:904-440-0998
Mailing Address - Fax:
Practice Address - Street 1:8380 BAYMEADOWS RD STE 17
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-7435
Practice Address - Country:US
Practice Address - Phone:904-440-0998
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-01
Last Update Date:2017-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
No261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)Group - Multi-Specialty
No261QR0208XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mobile