MEDICARE: NORTHSIDE IMAGING LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2085R0202X	Diagnostic Radiology Physician

General Provider Information

NPI Number	:	1063402279
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHSIDE IMAGING LLC

Provider Business Mailing Address
First Line	:	6006 49TH ST N
Second Line	:	STE 140
City	:	ST PETERSBURG
State	:	FL
Zip	:	33709-2148
Country	:	US
Telephone Number	:	727-528-5900
Fax Number	:	727-528-5911

Provider Business Practice Location Address
First Line	:	6006 49TH ST N
Second Line	:	STE 140
City	:	ST PETERSBURG
State	:	FL
Zip	:	33709-2148
Country	:	US
Telephone Number	:	727-528-5900
Fax Number	:	727-528-5911

Authorized Official
Title or Position	:	CREDENTIALING COORDINATOR
Name	:	MR. LAVELLE HARDIN
Credential	:
Telephone Number	:	615-344-8203

Provider Enumeration Date	:	10/27/2005
Last Update Date	:	08/28/2007

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