Basic Information
| Provider Information | |||||||||
| NPI: | 1477563484 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DOCTORS IMAGING GROUP LLC VASCULAR AND INTERVENTIONAL PHYSICIANS OFFIC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 147026 | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326147026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3523319729 | ||||||||
| FaxNumber: | 3523310136 | ||||||||
| Practice Location | |||||||||
| Address1: | 6685 NW 9TH BLVD | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326054206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3523337847 | ||||||||
| FaxNumber: | 3523330990 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2006 | ||||||||
| LastUpdateDate: | 05/02/2008 | ||||||||
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| AuthorizedOfficialLastName: | WARE | ||||||||
| AuthorizedOfficialFirstName: | DAN | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/ PRACTICING PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 3523319729 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | DOCTORS IMAGING GROUP LLC | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0204X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology |
ID Information
| ID | Type | State | Issuer | Description | 270855 | 01 | FL | AVMED GROUP | OTHER | CK3155 | 01 | FL | RRMC GROUP | OTHER | 259303304 | 05 | FL | MEDICAID | 45280 | 01 | FL | BC GROUP | OTHER | 259303300 | 05 | FL | MEDICAID |