Basic Information
| Provider Information | |||||||||
| NPI: | 1861495087 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MEDFUND LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | HORIZON TWO LLC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 240 N WASHINGTON BLVD | ||||||||
| Address2: | |||||||||
| City: | SARASOTA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342365945 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9419253490 | ||||||||
| FaxNumber: | 9519534452 | ||||||||
| Practice Location | |||||||||
| Address1: | 6220 MANATEE AVE W | ||||||||
| Address2: | STE 101 | ||||||||
| City: | BRADENTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342092303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9417618594 | ||||||||
| FaxNumber: | 9417613815 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | KERN | ||||||||
| AuthorizedOfficialFirstName: | MARTIN | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9419253490 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1200X | HCC5210 | FL | Y | Ambulatory Health Care Facilities | Clinic/Center | Magnetic Resonance Imaging (MRI) |
ID Information
| ID | Type | State | Issuer | Description | V2645 | 01 | FL | BCBS PROVIDER NUMBER | OTHER | 3411979 | 01 | AETNA HMO PROVIDER NUMBER | OTHER | 5079697 | 01 | AETNA PPO/POS PROV NUMBER | OTHER |