Basic Information
Provider Information | |||||||||
NPI: | 1497820948 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | IMED DIAGNOSTIC SERVICES OF SOUTHEAST FLORIDA LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | INMED DIAGNOSTIC SERVICES OF SOUTHEAST FLORIDA LLC | ||||||||
OtherOrganizationType: | 4 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 8903 GLADES RD | ||||||||
Address2: | SUITE B1 | ||||||||
City: | BOCA RATON | ||||||||
State: | FL | ||||||||
PostalCode: | 334344074 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5612189011 | ||||||||
FaxNumber: | 5612189012 | ||||||||
Practice Location | |||||||||
Address1: | 8903 GLADES RD | ||||||||
Address2: | SUITE B1 | ||||||||
City: | BOCA RATON | ||||||||
State: | FL | ||||||||
PostalCode: | 334344074 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5612189011 | ||||||||
FaxNumber: | 5612189012 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/21/2006 | ||||||||
LastUpdateDate: | 10/15/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | STERNBERG | ||||||||
AuthorizedOfficialFirstName: | ALAN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | MANAGING PARTNER | ||||||||
AuthorizedOfficialTelephone: | 5612189011 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0200X | HCC7491 | FL | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Radiology |
ID Information
ID | Type | State | Issuer | Description | V2949 | 01 | FL | BLUECROSS BLUESHIELD | OTHER |