Provider Demographics
NPI:1366569923
Name:INMED DIAGNOSTIC SERVICES OF MASSACHUSETTS LLC
Entity type:Organization
Organization Name:INMED DIAGNOSTIC SERVICES OF MASSACHUSETTS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:LONGTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-510-3704
Mailing Address - Street 1:2400 E COMMERCIAL BLVD
Mailing Address - Street 2:SUITE 826
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33308-4030
Mailing Address - Country:US
Mailing Address - Phone:954-510-3700
Mailing Address - Fax:954-510-2649
Practice Address - Street 1:434 ROUTE 134
Practice Address - Street 2:UNIT C-2
Practice Address - City:SOUTH DENNIS
Practice Address - State:MA
Practice Address - Zip Code:02660-3433
Practice Address - Country:US
Practice Address - Phone:508-398-3617
Practice Address - Fax:508-398-3763
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-26
Last Update Date:2014-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA236414261QR0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0206XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mammography
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1529650Medicaid
MA327100Medicare ID - Type Unspecified