MEDICARE: ASCENT DIAGNOSTIC IMAGING OF JACKSONVILLE 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	2085B0100X	Body Imaging Physician	ME59548	FL
2	2085D0003X	Diagnostic Neuroimaging (Radiology) Physician	ME59548	FL
3	2085N0700X	Neuroradiology Physician	ME59548	FL
4	2085R0202X	Diagnostic Radiology Physician	ME59548	FL

General Provider Information

NPI Number	:	1538333117
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ASCENT DIAGNOSTIC IMAGING OF JACKSONVILLE LLC

Provider Business Mailing Address
First Line	:	5210 BELFORT RD
Second Line	:	STE 130
City	:	JACKSONVILLE
State	:	FL
Zip	:	32256-6024
Country	:	US
Telephone Number	:	904-470-4000
Fax Number	:

Provider Business Practice Location Address
First Line	:	5210 BELFORT RD
Second Line	:	STE 130
City	:	JACKSONVILLE
State	:	FL
Zip	:	32256-6024
Country	:	US
Telephone Number	:	904-470-4000
Fax Number	:

Authorized Official
Title or Position	:	COO
Name	:	MICHAEL FAGIEN
Credential	:	MD
Telephone Number	:	813-496-1075

Provider Enumeration Date	:	04/15/2008
Last Update Date	:	06/03/2008

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