Healthcare Provider Details

I. General information

NPI: 1376716530
Provider Name (Legal Business Name): ADVANCED MOLECULAR IMAGING OF FLORIDA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2008
Last Update Date: 04/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2650 N MILITARY TRL
BOCA RATON FL
33431-6350
US

IV. Provider business mailing address

2650 N MILITARY TRL
BOCA RATON FL
33431-6350
US

V. Phone/Fax

Practice location:
  • Phone: 954-557-8408
  • Fax:
Mailing address:
  • Phone: 954-557-8408
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085D0003X
TaxonomyDiagnostic Neuroimaging (Radiology) Physician
License NumberME59548
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License NumberME59548
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberME59548
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License NumberME59548
License Number StateFL
# 5
Primary TaxonomyY
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License NumberME59548
License Number StateFL

VIII. Authorized Official

Name: MICHAEL FAGIEN
Title or Position: CEO
Credential: MD
Phone: 954-557-8408