MEDICARE: FORT WALTON DIAGNOSTIC IMAGING CENTER 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	261QM1300X	Multi-Specialty Clinic/Center	HCC4489	FL
2	261QR0200X	Radiology Clinic/Center	HCC4489	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	V2837	OTHER	FL	BCBS FL PROVIDER NO.
2	7732283	OTHER	FL	AETNA PROVIDER NO.

General Provider Information

NPI Number	:	1619920642
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FORT WALTON DIAGNOSTIC IMAGING CENTER LLC

Provider Business Mailing Address
First Line	:	1112 HOSPITAL RD
Second Line	:	SUITE C
City	:	FORT WALTON BEACH
State	:	FL
Zip	:	32547-6742
Country	:	US
Telephone Number	:	850-862-7070
Fax Number	:	850-862-0900

Provider Business Practice Location Address
First Line	:	1112 HOSPITAL RD
Second Line	:	SUITE C
City	:	FORT WALTON BEACH
State	:	FL
Zip	:	32547-6742
Country	:	US
Telephone Number	:	850-862-7070
Fax Number	:	850-862-0900

Authorized Official
Title or Position	:	MEMBER
Name	:	GARY MCMICHAEL
Credential	:
Telephone Number	:	850-862-7070

Provider Enumeration Date	:	05/19/2006
Last Update Date	:	09/11/2025

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