MEDICARE: FLORIDA DIAGNOSTIC IMAGING CENTER

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		FL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	E3017B	OTHER	FL	MEDICARE IDTF

General Provider Information

NPI Number	:	1407814106
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FLORIDA DIAGNOSTIC IMAGING CENTER

Provider Business Mailing Address
First Line	:	3480 PRESTON RIDGE RD STE 600
Second Line	:	CREDENTIALING DEPT
City	:	ALPHARETTA
State	:	GA
Zip	:	30005-5462
Country	:	US
Telephone Number	:	770-300-0101
Fax Number	:	770-300-0429

Provider Business Practice Location Address
First Line	:	16201 PANAMA CITY BEACH PKWY
Second Line	:	SUTIE 101
City	:	PANAMA CITY BEACH
State	:	FL
Zip	:	32413-5301
Country	:	US
Telephone Number	:	850-233-2868
Fax Number	:	850-233-2278

Authorized Official
Title or Position	:	COO
Name	:	MR. DANIEL J SCHAEFER
Credential	:
Telephone Number	:	770-300-0101

Provider Enumeration Date	:	05/02/2006
Last Update Date	:	09/23/2013

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