Basic Information
| Provider Information | |||||||||
| NPI: | 1679800726 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ALTAMONTE SPRINGS DIAGNOSTIC IMAGING, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PREMIER MEDICAL IMAGING | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1150 S SEMORAN BLVD | ||||||||
| Address2: | SUITE C | ||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328071424 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4074825253 | ||||||||
| FaxNumber: | 4074825254 | ||||||||
| 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: | 11/11/2009 | ||||||||
| LastUpdateDate: | 02/13/2013 | ||||||||
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| AuthorizedOfficialLastName: | LANDAU | ||||||||
| AuthorizedOfficialFirstName: | RONALD | ||||||||
| AuthorizedOfficialMiddleName: | I | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4074825253 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ALTAMONTE SPRINGS DIAGNOSTIC IMAGING, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.