MEDICARE: JOHNSON DIAGNOSTIC CENTER INC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QR0200X	Radiology Clinic/Center	CRT68355	FL

General Provider Information

NPI Number	:	1114389996
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JOHNSON DIAGNOSTIC CENTER INC

Provider Business Mailing Address
First Line	:	5917 JOHNSON ST
Second Line	:
City	:	HOLLYWOOD
State	:	FL
Zip	:	33021-5637
Country	:	US
Telephone Number	:	954-325-1826
Fax Number	:	954-415-8542

Provider Business Practice Location Address
First Line	:	5917 JOHNSON ST
Second Line	:
City	:	HOLLYWOOD
State	:	FL
Zip	:	33021-5637
Country	:	US
Telephone Number	:	954-325-1826
Fax Number	:	954-415-8542

Authorized Official
Title or Position	:	PRESIDENT
Name	:	CARLOS M CANCELL
Credential	:	CRT
Telephone Number	:	954-415-8541

Provider Enumeration Date	:	03/22/2016
Last Update Date	:	03/22/2016

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