Basic Information
| Provider Information | |||||||||
| NPI: | 1922172865 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | IMED DIAGNOSTIC SERVICES OF SOUTHWEST FLORIDA LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5650 STRAND CT | ||||||||
| Address2: | |||||||||
| City: | NAPLES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 341103343 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2395975530 | ||||||||
| FaxNumber: | 2395977825 | ||||||||
| Practice Location | |||||||||
| Address1: | 5650 STRAND CT | ||||||||
| Address2: | |||||||||
| City: | NAPLES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 341103343 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2395975530 | ||||||||
| FaxNumber: | 2395977825 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2006 | ||||||||
| LastUpdateDate: | 02/11/2009 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | STERNBERG | ||||||||
| AuthorizedOfficialFirstName: | ALAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 2395975530 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0200X | HCC7586 | FL | Y | Ambulatory Health Care Facilities | Clinic/Center | Radiology |
ID Information
| ID | Type | State | Issuer | Description | V2925 | 01 | FL | BLUECROSS PROVIDER | OTHER |