MEDICARE: FLORIDA DIAGNOSTIC IMAGING CENTER INC

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		FL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	470000877	OTHER	FL	RR MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	SG076081	OTHER	FL	VISTA SUNRISE
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	7501697	OTHER	FL	AETNA
5	V2704	OTHER	FL	BCBS FLORIDA
6	2050236	OTHER	FL	UNITED HEALTHCARE

General Provider Information

NPI Number	:	1225096936
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FLORIDA DIAGNOSTIC IMAGING CENTER INC

Provider Business Mailing Address
First Line	:	1642 WESTGATE CIR STE 202
Second Line	:
City	:	BRENTWOOD
State	:	TN
Zip	:	37027-8195
Country	:	US
Telephone Number	:	615-713-7519
Fax Number	:

Provider Business Practice Location Address
First Line	:	2525 MARTIN LUTHER KING JR. BLVD
Second Line	:
City	:	PANAMA CITY
State	:	FL
Zip	:	32405-4414
Country	:	US
Telephone Number	:	850-873-6900
Fax Number	:	850-873-6902

Authorized Official
Title or Position	:	COO
Name	:	RAIF ERIM
Credential	:
Telephone Number	:	615-713-7519

Provider Enumeration Date	:	05/02/2006
Last Update Date	:	06/14/2021

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