MEDICARE: ULTRA 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	261QM2500X	Medical Specialty Clinic/Center

General Provider Information

NPI Number	:	1326232315
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ULTRA DIAGNOSTIC IMAGING, INC

Provider Business Mailing Address
First Line	:	3945 WELLINGTON PKWY
Second Line	:
City	:	PALM HARBOR
State	:	FL
Zip	:	34685-1172
Country	:	US
Telephone Number	:	215-760-0766
Fax Number	:

Provider Business Practice Location Address
First Line	:	3687 TAMPA RD
Second Line	:	SUITE 202
City	:	OLDSMAR
State	:	FL
Zip	:	34677-6307
Country	:	US
Telephone Number	:	813-925-3343
Fax Number	:	813-854-2929

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. STEPHEN MARK MITCHELL
Credential	:	D.O.
Telephone Number	:	215-760-0766

Provider Enumeration Date	:	09/01/2007
Last Update Date	:	09/01/2007

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