MEDICARE: ALTAMONTE SPRINGS DIAGNOSTIC IMAGING 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
2	2085R0202X	Diagnostic Radiology Physician	HCC4173	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	V2219	OTHER	FL	BCBS PROVIDER NUMBER

General Provider Information

NPI Number	:	1275639767
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ALTAMONTE SPRINGS DIAGNOSTIC IMAGING INC

Provider Business Mailing Address
First Line	:	1150 S. SEMORAN BLVD
Second Line	:	SUITE C
City	:	ORLANDO
State	:	FL
Zip	:	32807-1424
Country	:	US
Telephone Number	:	407-482-5253
Fax Number	:	407-482-5254

Provider Business Practice Location Address
First Line	:	195 S. WESTMONTE DR
Second Line	:	SUITE 1118
City	:	ALTAMONTE SPRINGS
State	:	FL
Zip	:	32714-4219
Country	:	US
Telephone Number	:	407-786-5877
Fax Number	:	407-786-5803

Authorized Official
Title or Position	:	OWNER
Name	:	DR. RONALD I LANDAU
Credential	:	M.D.
Telephone Number	:	407-482-5253

Provider Enumeration Date	:	09/15/2006
Last Update Date	:	04/04/2011

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