MEDICARE: PRESTIGE IMAGING 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	2085R0202X	Diagnostic Radiology Physician		FL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	DE3457	OTHER	FL	RR MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	V3087	OTHER	FL	BCBS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1578503165
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRESTIGE IMAGING LLC

Provider Business Mailing Address
First Line	:	PO BOX 919028
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32891-9028
Country	:	US
Telephone Number	:	727-793-9300
Fax Number	:	727-793-0052

Provider Business Practice Location Address
First Line	:	2415 UNIVERSITY PKWY
Second Line	:	UNIVERSITY HEALTH PARK, BUILING 3, SUITE 112
City	:	SARASOTA
State	:	FL
Zip	:	34243-2809
Country	:	US
Telephone Number	:	941-487-2130
Fax Number	:	941-487-2138

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. RICHARD JAY LICHTENSTEIN
Credential	:	MD
Telephone Number	:	941-487-2550

Provider Enumeration Date	:	06/08/2006
Last Update Date	:	03/05/2009

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Directions to “PRESTIGE IMAGING LLC ” Practice Location

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