Basic Information
| Provider Information | |||||||||
| NPI: | 1700877602 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PALMS WEST IMAGING INC | ||||||||
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| OtherOrganizationName: | PALMS WEST OPEN MRI - RPB | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11337 OKEECHOBEE BLVD | ||||||||
| Address2: | SUITE B | ||||||||
| City: | ROYAL PALM BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334118732 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5617955558 | ||||||||
| FaxNumber: | 5617927300 | ||||||||
| Practice Location | |||||||||
| Address1: | 11337 OKEECHOBEE BLVD | ||||||||
| Address2: | SUITE B | ||||||||
| City: | ROYAL PALM BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334118732 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5617955558 | ||||||||
| FaxNumber: | 5617927300 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | HUBER | ||||||||
| AuthorizedOfficialFirstName: | JONATHAN | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5617959150 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1200X | HCC1448 | FL | Y | Ambulatory Health Care Facilities | Clinic/Center | Magnetic Resonance Imaging (MRI) |
ID Information
| ID | Type | State | Issuer | Description | V2350 | 01 | FL | BCBS IDTF | OTHER |