Healthcare Provider Details

I. General information

NPI: 1851997985
Provider Name (Legal Business Name): DIAGNOSTIC CLINIC MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2020
Last Update Date: 03/16/2021
Certification Date: 03/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1615 PASADENA AVE S STE 220
SOUTH PASADENA FL
33707-4517
US

IV. Provider business mailing address

1615 PASADENA AVE S STE 220
SOUTH PASADENA FL
33707-4517
US

V. Phone/Fax

Practice location:
  • Phone: 727-345-7100
  • Fax: 727-345-7102
Mailing address:
  • Phone: 727-345-7100
  • Fax: 727-345-7102

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 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