MEDICARE: FLORIDA 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	261QR0200X	Radiology Clinic/Center	HCC5282	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	102370	OTHER	FL	AVMED
2	40016	OTHER	FL	FLORIDIANCARE
3	FDA 155978	OTHER	FL	EMBRACED PROGRAM
4	V2489	OTHER	FL	BCBS OF FLORIDA
5	1209448	OTHER	FL	FIRST HEALTH/MAIL HANDLER
6	16-00554	OTHER	FL	UNITEDHEALTHCARE MEDIPASS
7	17030	OTHER	FL	STAYWELL/WELLCARE
8	288660	OTHER	FL	AMERIGROUP
9	1488395	OTHER	FL	UNITED HEALTHCARE
10	17030	OTHER	FL	HEALTHEASE
11	OS0004065	OTHER	FL	WORKERS COMPENSATION
12	0782103	OTHER	FL	CIGNA
13	8208068	OTHER	FL	AETNA
14	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1356305767
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FLORIDA DIAGNOSTIC IMAGING INC

Provider Business Mailing Address
First Line	:	5201 BABCOCK ST NE
Second Line	:	SUITE 5
City	:	PALM BAY
State	:	FL
Zip	:	32905-4637
Country	:	US
Telephone Number	:	321-676-5323
Fax Number	:	321-951-9253

Provider Business Practice Location Address
First Line	:	5201 BABCOCK ST NE
Second Line	:	SUITE 5
City	:	PALM BAY
State	:	FL
Zip	:	32905-4637
Country	:	US
Telephone Number	:	321-676-5323
Fax Number	:	321-951-9253

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. IAN LANDIS
Credential	:	DO
Telephone Number	:	321-676-5323

Provider Enumeration Date	:	04/13/2006
Last Update Date	:	12/13/2007

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