Provider Demographics
NPI:1871555482
Name:JUPITER EFL IMAGING CENTER LLC
Entity type:Organization
Organization Name:JUPITER EFL IMAGING CENTER LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP IMAGING SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:WANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:FOGARTY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-838-3630
Mailing Address - Street 1:875 MILITARY TRL
Mailing Address - Street 2:SUITE 101
Mailing Address - City:JUPITER
Mailing Address - State:FL
Mailing Address - Zip Code:33458-5700
Mailing Address - Country:US
Mailing Address - Phone:561-748-9828
Mailing Address - Fax:561-748-2490
Practice Address - Street 1:875 MILITARY TRL
Practice Address - Street 2:SUITE 101
Practice Address - City:JUPITER
Practice Address - State:FL
Practice Address - Zip Code:33458-5700
Practice Address - Country:US
Practice Address - Phone:561-748-9828
Practice Address - Fax:561-748-2490
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-06
Last Update Date:2010-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL272378600Medicaid
FL272378600Medicaid