Healthcare Provider Details

I. General information

NPI: 1891070256
Provider Name (Legal Business Name): RADIOLOGY OF MSMC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2011
Last Update Date: 09/22/2021
Certification Date: 09/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4300 ALTON RD
MIAMI BEACH FL
33140-2948
US

IV. Provider business mailing address

PO BOX 11550
MIAMI FL
33101-1550
US

V. Phone/Fax

Practice location:
  • Phone: 305-503-5610
  • Fax:
Mailing address:
  • Phone: 305-674-2680
  • Fax: 305-674-3919

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberME104939
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code2085R0203X
TaxonomyTherapeutic Radiology Physician
License NumberME104939
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberME104939
License Number StateFL

VIII. Authorized Official

Name: WAYNE CHUTKAN
Title or Position: VP OF FINANCE
Credential:
Phone: 305-674-2662