=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154517191
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DIAGNOSTIC MD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/24/2007
-----------------------------------------------------
Last Update Date | 09/24/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5245 SW 38TH AVE
-----------------------------------------------------
City | FT LAUDERDALE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33312-8227
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-646-1212
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5245 SW 38TH AVE
-----------------------------------------------------
City | FT LAUDERDALE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33312-8227
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-646-1212
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MR. MIKE ROZENBERG
-----------------------------------------------------
Credential | RPSGT
-----------------------------------------------------
Telephone | 954-646-1212
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 246ZE0500X
-----------------------------------------------------
Taxonomy Name | EEG Specialist/Technologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------