Provider Demographics
NPI:1861535536
Name:CARDIOVASCULAR DIAGNOSTIC IMAGE INC
Entity type:Organization
Organization Name:CARDIOVASCULAR DIAGNOSTIC IMAGE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EDELIO
Authorized Official - Middle Name:
Authorized Official - Last Name:MIRABOLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-480-2000
Mailing Address - Street 1:7171 SW 24TH ST
Mailing Address - Street 2:SUITE 311
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33155-1692
Mailing Address - Country:US
Mailing Address - Phone:305-480-2000
Mailing Address - Fax:305-480-2003
Practice Address - Street 1:7171 SW 24TH ST
Practice Address - Street 2:SUITE 311
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33155-1692
Practice Address - Country:US
Practice Address - Phone:305-480-2000
Practice Address - Fax:305-480-2003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-14
Last Update Date:2016-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLHCC6687261QM1300X, 261QR0206X
FLHCC10640261QR0206X, 261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0206XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mammography
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL261881800Medicaid
FL261881800Medicaid