MEDICARE: MEDICAL DIAGNOSTIC SERVICE

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
2	2085B0100X	Body Imaging Physician

General Provider Information

NPI Number	:	1235344516
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MEDICAL DIAGNOSTIC SERVICE

Provider Business Mailing Address
First Line	:	2300 CORPORATE CIR
Second Line	:	190
City	:	HENDERSON
State	:	NV
Zip	:	89074-7724
Country	:	US
Telephone Number	:	702-318-2484
Fax Number	:	702-932-8587

Provider Business Practice Location Address
First Line	:	700 E WARM SPRINGS RD
Second Line	:	301
City	:	LAS VEGAS
State	:	NV
Zip	:	89119-4305
Country	:	US
Telephone Number	:	702-318-2484
Fax Number	:	702-932-8587

Authorized Official
Title or Position	:	CREDENTIALING SPECIALIST
Name	:	MALISSA THATCHER
Credential	:
Telephone Number	:	702-932-8547

Provider Enumeration Date	:	05/11/2007
Last Update Date	:	09/17/2007

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Directions to “MEDICAL DIAGNOSTIC SERVICE ” Practice Location

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