Provider Demographics
NPI:1053346643
Name:PEMBROKE PINES MRI INC
Entity type:Organization
Organization Name:PEMBROKE PINES MRI INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:HOWARD
Authorized Official - Middle Name:STEPHAN
Authorized Official - Last Name:DEKKERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-566-4551
Mailing Address - Street 1:PO BOX 5206
Mailing Address - Street 2:
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33310-5206
Mailing Address - Country:US
Mailing Address - Phone:954-566-4551
Mailing Address - Fax:954-566-4565
Practice Address - Street 1:10950 PINES BLVD
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33026-5216
Practice Address - Country:US
Practice Address - Phone:954-566-4551
Practice Address - Fax:954-566-4565
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-11
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)
No261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLV2624OtherBLUE CROSS BLUE SHIELD
FL7555441OtherAETNA
FLV2624OtherBLUE CROSS BLUE SHIELD