MEDICARE: EAST CENTRAL FLORIDA OUTPATIENT IMAGING LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number State
1	2085B0100X	Body Imaging Physician	FL
2	2085N0700X	Neuroradiology Physician	FL
3	2085N0904X	Nuclear Radiology Physician	FL
4	2085P0229X	Pediatric Radiology Physician	FL
5	2085R0203X	Therapeutic Radiology Physician	FL
6	2085R0204X	Vascular & Interventional Radiology Physician	FL
7	2085U0001X	Diagnostic Ultrasound Physician	FL
8	2085R0202X	Diagnostic Radiology Physician	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	V2885	OTHER	FL	BLUE CROSS

General Provider Information

NPI Number	:	1093757486
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EAST CENTRAL FLORIDA OUTPATIENT IMAGING LLC

Provider Business Mailing Address
First Line	:	1673 MASON AVE
Second Line	:	SUITE 305
City	:	DAYTONA BEACH
State	:	FL
Zip	:	32117-5515
Country	:	US
Telephone Number	:	386-274-7118
Fax Number	:	386-274-6173

Provider Business Practice Location Address
First Line	:	1195 DUNLAWTON AVE
Second Line	:
City	:	PORT ORANGE
State	:	FL
Zip	:	32127-4745
Country	:	US
Telephone Number	:	386-763-5300
Fax Number	:	386-322-1616

Authorized Official
Title or Position	:	CEO
Name	:	MR. AL FALCO
Credential	:
Telephone Number	:	386-274-7118

Provider Enumeration Date	:	06/12/2006
Last Update Date	:	02/08/2010

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Directions to “EAST CENTRAL FLORIDA OUTPATIENT IMAGING LLC ” Practice Location

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