Provider Demographics
NPI:1528473402
Name:RX IMAGING OF SWFL LLC
Entity type:Organization
Organization Name:RX IMAGING OF SWFL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:L
Authorized Official - Last Name:TANNENBAUM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:239-292-6669
Mailing Address - Street 1:506 SE 47TH TER
Mailing Address - Street 2:SUITE A
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33904-8517
Mailing Address - Country:US
Mailing Address - Phone:239-541-5444
Mailing Address - Fax:239-471-2674
Practice Address - Street 1:506 SE 47TH TER
Practice Address - Street 2:SUITE A
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33904-8517
Practice Address - Country:US
Practice Address - Phone:239-541-5444
Practice Address - Fax:239-471-2674
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-30
Last Update Date:2015-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X
FLME64512174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL606072OtherHEALTH CARE CLINIC ESTABLISHMENT
FM10D2082062OtherCLIA CERTIFICATE OF WAIVER
FL013199600Medicaid
FM10D2082062OtherCLIA CERTIFICATE OF WAIVER