Healthcare Provider Details

I. General information

NPI: 1124690433
Provider Name (Legal Business Name): DIAGNOSTIC CLINIC MEDICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2021
Last Update Date: 07/15/2021
Certification Date: 07/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6735 CROSSWINDS DR N
SAINT PETERSBURG FL
33710-5471
US

IV. Provider business mailing address

6735 CROSSWINDS DR N
SAINT PETERSBURG FL
33710-5471
US

V. Phone/Fax

Practice location:
  • Phone: 727-548-8500
  • Fax: 727-501-7328
Mailing address:
  • Phone: 727-548-8500
  • Fax: 727-501-7328

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: GINA MARIE PREBECK
Title or Position: VP OF OPERATIONS
Credential:
Phone: 727-559-9461