Basic Information
| Provider Information | |||||||||
| NPI: | 1215070776 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | IMED DIAGNOSTIC SERVICES OF BONITA SPRINGS LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9400 BONITA BEACH RD SE | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | BONITA SPRINGS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 341354515 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2395975530 | ||||||||
| FaxNumber: | 2395977825 | ||||||||
| Practice Location | |||||||||
| Address1: | 9400 BONITA BEACH RD SE | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | BONITA SPRINGS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 341354515 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2395975530 | ||||||||
| FaxNumber: | 2395977825 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2007 | ||||||||
| LastUpdateDate: | 10/17/2008 | ||||||||
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| AuthorizedOfficialLastName: | STERNBERG | ||||||||
| AuthorizedOfficialFirstName: | ALAN | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2395975530 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | PENDING | FL | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
| ID | Type | State | Issuer | Description | PENDING | 01 | FL | STATE LICENSURE | OTHER |