=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194728014
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NATIONAL P E T SCAN BROWARD LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/24/2005
-----------------------------------------------------
Last Update Date | 12/05/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6290 N FEDERAL HWY
-----------------------------------------------------
City | FT LAUDERDALE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33308-1917
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-332-3000
-----------------------------------------------------
Fax | 954-332-2671
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6622 SOUTHPOINT DR S SUITE 360
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32216-8014
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-358-8441
-----------------------------------------------------
Fax | 904-358-2288
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATIVE ASSISTANT
-----------------------------------------------------
Name | MS. MARGIE FAYE AUSTIN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 904-358-8441
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0200X
-----------------------------------------------------
Taxonomy Name | Radiology Clinic/Center
-----------------------------------------------------
License Number | HCC5688
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------