Provider Demographics
NPI:1801437041
Name:PREMIER INTERVENTIONAL AND DIAGNOSTIC RADIOLOGY CORP
Entity type:Organization
Organization Name:PREMIER INTERVENTIONAL AND DIAGNOSTIC RADIOLOGY CORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EMILIO
Authorized Official - Middle Name:
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:786-547-7655
Mailing Address - Street 1:7556 LAKE WORTH RD STE 103
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33467-2503
Mailing Address - Country:US
Mailing Address - Phone:561-894-1370
Mailing Address - Fax:561-894-1372
Practice Address - Street 1:7556 LAKE WORTH RD STE 103
Practice Address - Street 2:
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33467-2503
Practice Address - Country:US
Practice Address - Phone:561-894-1370
Practice Address - Fax:561-894-1372
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-30
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL104439200Medicaid