MEDICARE: SHORES DIAGNOSTIC 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

General Provider Information

NPI Number	:	1376675538
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SHORES DIAGNOSTIC CENTER INC

Provider Business Mailing Address
First Line	:	PO BOX 530506
Second Line	:
City	:	MIAMI SHORES
State	:	FL
Zip	:	33153-0506
Country	:	US
Telephone Number	:	305-759-0074
Fax Number	:

Provider Business Practice Location Address
First Line	:	8855 NE 2ND AVE
Second Line	:
City	:	EL PORTAL
State	:	FL
Zip	:	33138
Country	:	US
Telephone Number	:	305-759-0074
Fax Number	:	305-754-4766

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MIRNELLE JOSMA
Credential	:	AS RTM
Telephone Number	:	305-759-0074

Provider Enumeration Date	:	03/12/2007
Last Update Date	:	08/22/2020

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