MEDICARE: MADRID, LLC

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	261QM1200X	Magnetic Resonance Imaging (MRI) Clinic/Center	HCC5165	FL

General Provider Information

NPI Number	:	1477725893
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MADRID, LLC

Provider Business Mailing Address
First Line	:	7201 N PINE ISLAND RD
Second Line	:
City	:	TAMARAC
State	:	FL
Zip	:	33321-2517
Country	:	US
Telephone Number	:	954-720-0903
Fax Number	:	954-720-4583

Provider Business Practice Location Address
First Line	:	7201 N PINE ISLAND RD
Second Line	:
City	:	TAMARAC
State	:	FL
Zip	:	33321-2517
Country	:	US
Telephone Number	:	954-720-0903
Fax Number	:	954-720-4583

Authorized Official
Title or Position	:	MANAGING PARTNER
Name	:	MR. MIROSLAV JAKSIC
Credential	:
Telephone Number	:	810-623-3211

Provider Enumeration Date	:	03/25/2008
Last Update Date	:	03/25/2008

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