MEDICARE: PREMIERESCAN PC

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	261QR0200X	Radiology Clinic/Center	G59447	CA

General Provider Information

NPI Number	:	1083720304
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PREMIERESCAN PC

Provider Business Mailing Address
First Line	:	2324 MONTPELIER DR STE 7
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95116-1612
Country	:	US
Telephone Number	:	669-263-6344
Fax Number	:	408-708-4454

Provider Business Practice Location Address
First Line	:	2324 MONTPELIER DR STE 7
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95116-1612
Country	:	US
Telephone Number	:	669-263-6344
Fax Number	:	408-708-4454

Authorized Official
Title or Position	:	DIRECTOR OF OPERATIONS
Name	:	BRITTANY LYNN SEMIDES
Credential	:
Telephone Number	:	408-217-2803

Provider Enumeration Date	:	08/21/2006
Last Update Date	:	02/28/2018

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