Healthcare Provider Details

I. General information

NPI: 1336378165
Provider Name (Legal Business Name): RIVERSIDE MEDICAL DIAGNOSTIC AND IMAGING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2009
Last Update Date: 09/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2151 RIVERSIDE AVE
JACKSONVILLE FL
32204-4416
US

IV. Provider business mailing address

2151 RIVERSIDE AVE
JACKSONVILLE FL
32204-4416
US

V. Phone/Fax

Practice location:
  • Phone: 904-389-6707
  • Fax: 904-389-6717
Mailing address:
  • Phone: 904-389-6707
  • Fax: 904-389-6717

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1200X
TaxonomyMagnetic Resonance Imaging (MRI) Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QR0206X
TaxonomyMammography Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. CORBY MARSHALL
Title or Position: MANAGING PARTNER
Credential:
Phone: 912-253-0375