Healthcare Provider Details

I. General information

NPI: 1295487593
Provider Name (Legal Business Name): CONCIERGE RADIOLOGY GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/19/2022
Last Update Date: 07/07/2022
Certification Date: 07/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 WEST AVE APT 705
MIAMI BEACH FL
33139-6797
US

IV. Provider business mailing address

520 WEST AVE APT 705
MIAMI BEACH FL
33139-6797
US

V. Phone/Fax

Practice location:
  • Phone: 516-509-3755
  • Fax:
Mailing address:
  • Phone: 516-509-3755
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: GUSTAVO PANTOL
Title or Position: EMPLOYEE
Credential:
Phone: 516-509-3755