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Contract Details
Facility name
Fountain Imaging
Provider ID
P000005544
NPI
1881865079
Tax ID
260627441
Effective Date
4/1/2012
Last Updated
10/23/2012
Direct Contract
Yes
Status
Active
Contract Discounts
Discount Type
S
State Fee Schedule Multiplier
76.00
Location Details
Address
One Northeast 167th St
North Miami Beach, FL 33162
United States
County
Miami-Dade
Phone
3057704343
(
Phone
)
Billing Details
Address
5429 LBJ Freeway
Suite 700
Dallas, TX 75240
Specialty Type
Diagnostic Services
Map
Address