MEDICARE: SUPERIOR DIAGNOSTIC STUDIES

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	291U00000X	Clinical Medical Laboratory

General Provider Information

NPI Number	:	1447579057
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUPERIOR DIAGNOSTIC STUDIES

Provider Business Mailing Address
First Line	:	9030 W FT IS TRL STE 11A
Second Line	:
City	:	CRYSTAL RIVER
State	:	FL
Zip	:	34429-2415
Country	:	US
Telephone Number	:	352-302-3535
Fax Number	:

Provider Business Practice Location Address
First Line	:	9030 W FT IS TRL STE 11A
Second Line	:
City	:	CRYSTAL RIVER
State	:	FL
Zip	:	34429-2415
Country	:	US
Telephone Number	:	352-302-3535
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. JEROD JOHN ROMANIK
Credential	:
Telephone Number	:	352-302-3535

Provider Enumeration Date	:	05/21/2010
Last Update Date	:	05/21/2010

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