Basic Information
| Provider Information | |||||||||
| NPI: | 1982686366 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHERN CARDIAC NUCLEAR IMAGING LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 144333 | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328144333 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4074229831 | ||||||||
| FaxNumber: | 4076482065 | ||||||||
| Practice Location | |||||||||
| Address1: | 6484 FORT CAROLINE RD | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322772042 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3523325755 | ||||||||
| FaxNumber: | 8668879246 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/19/2005 | ||||||||
| LastUpdateDate: | 01/10/2011 | ||||||||
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| AuthorizedOfficialLastName: | BURKE | ||||||||
| AuthorizedOfficialFirstName: | FLOYD | ||||||||
| AuthorizedOfficialMiddleName: | W. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3523328991 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207UN0901X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Nuclear Medicine | Nuclear Cardiology |
ID Information
| ID | Type | State | Issuer | Description | P00224933 | 01 | RAILROAD MEDICARE | OTHER |