Provider Demographics
NPI:1124690433
Name:DIAGNOSTIC CLINIC MEDICAL GROUP INC
Entity type:Organization
Organization Name:DIAGNOSTIC CLINIC MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:GINA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:PREBECK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-559-9461
Mailing Address - Street 1:6735 CROSSWINDS DR N
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33710-5471
Mailing Address - Country:US
Mailing Address - Phone:727-548-8500
Mailing Address - Fax:727-501-7328
Practice Address - Street 1:6735 CROSSWINDS DR N
Practice Address - Street 2:
Practice Address - City:SAINT PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33710-5471
Practice Address - Country:US
Practice Address - Phone:727-548-8500
Practice Address - Fax:727-501-7328
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DIAGNOSTIC CLINIC MEDICAL GROUP INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-07-15
Last Update Date:2021-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL00036OtherFLORIDA BLUE