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General NPI Number Information
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NPI Number | 1790982866
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Entity Type | Organization
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Legal Business Name | MEDX DIAGNOSTIC SERVICE
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Dates
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Enumeration Date | 07/01/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 4707 140TH AVE N SUITE 107
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City | CLEARWATER
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State | FL
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Zip | 33762-3834
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Country | US
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Telephone | 727-942-1465
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Fax |
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Provider Business Mailing Address
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Address Line | 4707 140TH AVE N SUITE 107
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City | CLEARWATER
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State | FL
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Zip | 33762-3834
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Country | US
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Telephone | 727-942-1465
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Fax |
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Authorized Official
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Title or Position | MANAGEER
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Name | MR. JOHN F EGAN
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Credential |
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Telephone | 727-942-1465
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | 5115
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License Number State | FL
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