Provider Demographics
NPI:1538833454
Name:DIAGNOSTIC CLINIC MEDICAL GROUP, INC.
Entity type:Organization
Organization Name:DIAGNOSTIC CLINIC MEDICAL GROUP, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:GINA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:PREBECK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-559-9461
Mailing Address - Street 1:385 CYPRESS GARDENS BLVD
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33880-4452
Mailing Address - Country:US
Mailing Address - Phone:863-356-3754
Mailing Address - Fax:863-356-5200
Practice Address - Street 1:385 CYPRESS GARDENS BLVD
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33880-4452
Practice Address - Country:US
Practice Address - Phone:863-356-3754
Practice Address - Fax:863-356-5200
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DIAGNOSTIC CLINIC MEDICAL GROUP, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-08-04
Last Update Date:2021-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL00036OtherFLORIDA BLUE