Provider Demographics
NPI:1194729665
Name:EXCEL DIAGNOSTIC SERVICES LLC
Entity type:Organization
Organization Name:EXCEL DIAGNOSTIC SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:PREM
Authorized Official - Middle Name:D
Authorized Official - Last Name:JAGERNAUTH
Authorized Official - Suffix:
Authorized Official - Credentials:RVT,RDMS,RDCS
Authorized Official - Phone:727-521-0129
Mailing Address - Street 1:1109 DARLINGTON OAK DR NE
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33703-6314
Mailing Address - Country:US
Mailing Address - Phone:727-521-0129
Mailing Address - Fax:727-521-0130
Practice Address - Street 1:1109 DARLINGTON OAK DR NE
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33703-6314
Practice Address - Country:US
Practice Address - Phone:727-521-0129
Practice Address - Fax:727-521-0130
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-12
Last Update Date:2007-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLHCC5616293D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes293D00000XLaboratoriesPhysiological Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL3580285OtherAETNA
FLV2896OtherBLUE CROSS BLUE SHIELD
FL3580285OtherAETNA