=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578210886
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FLORIDA DIAGNOSTIC IMAGING CENTER INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/07/2022
-----------------------------------------------------
Last Update Date | 03/07/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2525 MARTIN LUTHER KING JR BLVD
-----------------------------------------------------
City | PANAMA CITY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32405-4414
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-873-6900
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3024 BUSINESS PARK CIR
-----------------------------------------------------
City | GOODLETTSVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37072-3132
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 615-854-3409
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING DIRECTOR
-----------------------------------------------------
Name | SUSAN FENTON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 615-854-3409
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0208X
-----------------------------------------------------
Taxonomy Name | Mobile Radiology Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------