=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104637537
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | IMPRESSION IMAGING LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/15/2025
-----------------------------------------------------
Last Update Date | 01/15/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3111 N UNIVERSITY DR STE 115
-----------------------------------------------------
City | CORAL SPRINGS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33065-5049
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-580-2780
-----------------------------------------------------
Fax | 954-580-2790
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 21422
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10087-1422
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-577-9062
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR
-----------------------------------------------------
Name | MICHAEL FAGIEN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 954-580-2780
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------