Provider Demographics
NPI:1194728014
Name:NATIONAL P E T SCAN BROWARD LLC
Entity type:Organization
Organization Name:NATIONAL P E T SCAN BROWARD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE ASSISTANT
Authorized Official - Prefix:MS
Authorized Official - First Name:MARGIE
Authorized Official - Middle Name:FAYE
Authorized Official - Last Name:AUSTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-358-8441
Mailing Address - Street 1:6622 SOUTHPOINT DR S
Mailing Address - Street 2:SUITE 360
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-8014
Mailing Address - Country:US
Mailing Address - Phone:904-358-8441
Mailing Address - Fax:904-358-2288
Practice Address - Street 1:6290 N FEDERAL HWY
Practice Address - Street 2:
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33308-1917
Practice Address - Country:US
Practice Address - Phone:954-332-3000
Practice Address - Fax:954-332-2671
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-24
Last Update Date:2012-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLHCC5688261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL196704OtherWELLCARE
FL2630670OtherAETNA - HMO
FL593688943OtherTRICARE
FLCK2451OtherMEDICARE RAILROAD RETIREM
FL38830OtherNEIGHBORHOOD
FL67826OtherFOUNDATION
FLV2274OtherBLUE CROSS BLUE SHIELD FL
FL593688943OtherHUMANA
FLSG011169OtherVISTA
FL6958176-001OtherCIGNA
FL7441285OtherAETNA - PPO
FL7441285OtherAETNA - PPO