Basic Information
Provider Information | |||||||||
NPI: | 1871806133 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | IMEDICAL DIAGNOSTIC IMAGING CENTER OF NAPLES, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1350 TAMIAMI TRAIL NORTH | ||||||||
Address2: |   | ||||||||
City: | NAPLES | ||||||||
State: | FL | ||||||||
PostalCode: | 341025209 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2394304674 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 500 WEST MAIN STREET | ||||||||
Address2: | SUITE 108 | ||||||||
City: | BABYLON | ||||||||
State: | NY | ||||||||
PostalCode: | 117023028 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6312402277 | ||||||||
FaxNumber: | 6315178007 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/15/2010 | ||||||||
LastUpdateDate: | 07/15/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | STERNBERG | ||||||||
AuthorizedOfficialFirstName: | ALAN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | GENERAL PARTNER | ||||||||
AuthorizedOfficialTelephone: | 2394304674 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | HCC8783 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.