Provider Demographics
NPI:1427051887
Name:FLORIDA DIAGNOSTIC PORTABLE IMAGING, INC
Entity type:Organization
Organization Name:FLORIDA DIAGNOSTIC PORTABLE IMAGING, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:D
Authorized Official - Last Name:COTTI
Authorized Official - Suffix:
Authorized Official - Credentials:RT(R)
Authorized Official - Phone:321-984-8001
Mailing Address - Street 1:5201 BABCOCK ST NE
Mailing Address - Street 2:STE 2
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32905-4637
Mailing Address - Country:US
Mailing Address - Phone:321-984-8001
Mailing Address - Fax:321-728-0523
Practice Address - Street 1:5201 BABCOCK ST NE
Practice Address - Street 2:STE 2
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32905-4637
Practice Address - Country:US
Practice Address - Phone:321-984-8001
Practice Address - Fax:321-728-0523
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-31
Last Update Date:2008-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335V00000XSuppliersPortable X-ray and/or Other Portable Diagnostic Imaging Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLW9833OtherBLUE SHIELD XRAY
FL030398400Medicaid
FLW9833OtherBLUE SHIELD XRAY
FL1425185Medicare PIN
FL300006774Medicare PIN