Healthcare Provider Details

I. General information

NPI: 1770579732
Provider Name (Legal Business Name): VYMED DIAGNOSTIC IMAGING TAMPA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2005
Last Update Date: 05/05/2021
Certification Date: 05/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10010 N DALE MABRY HWY
TAMPA FL
33618-4469
US

IV. Provider business mailing address

10010 N DALE MABRY HWY STE. 100
TAMPA FL
33618-4469
US

V. Phone/Fax

Practice location:
  • Phone: 813-264-7176
  • Fax:
Mailing address:
  • Phone: 813-264-7176
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085N0904X
TaxonomyNuclear Radiology Physician
License NumberME71211
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ERIC COTTON
Title or Position: PARTNER
Credential: MD
Phone: 813-264-7176