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NPI Code Detail

MEDICARE: NEURO DX SERVICES LLC

MEDICARE: NEURO DX SERVICES 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
1111NN0400XNeurology ChiropractorCH8431FL
2208D00000XGeneral Practice PhysicianOS7123FL
3293D00000XPhysiological LaboratoryFL
4204R00000XElectrodiagnostic Medicine PhysicianOS7123FL

General Provider Information

NPI Number : 1649504515
Entity Type Code : Organization
Provider Name (Legal Business Name) : NEURO DX SERVICES LLC
Provider Business Mailing Address
First Line : 15880 SUMMERLIN RD STE 300
Second Line : PMB 106
City : FORT MYERS
State : FL
Zip : 33908-9613
Country : US
Telephone Number : 239-482-0300
Fax Number : 239-482-4757
Provider Business Practice Location Address
First Line : 8801 COLLEGE PKWY
Second Line : SUITE 2
City : FORT MYERS
State : FL
Zip : 33919-4882
Country : US
Telephone Number : 239-482-0300
Fax Number : 239-482-4757
Authorized Official
Title or Position : PRESIDENT
Name : GEORGE S PETRYK
Credential : DC,DACNB,FACFN,FABES
Telephone Number : 239-482-0300
Provider Enumeration Date : 09/25/2009
Last Update Date : 06/14/2012

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