=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831200211
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ADVANCED IMAGING CENTER OF CLERMONT, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/31/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 262 MOHAWK RD
-----------------------------------------------------
City | CLERMONT
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34715-7433
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-243-2111
-----------------------------------------------------
Fax | 352-243-2112
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 262 MOHAWK RD
-----------------------------------------------------
City | CLERMONT
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34715-7433
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-243-2111
-----------------------------------------------------
Fax | 352-243-2112
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. ROMAN DUBSKY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 407-927-1147
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0200X
-----------------------------------------------------
Taxonomy Name | Radiology Clinic/Center
-----------------------------------------------------
License Number | HCC4848
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------