Organization
FORT WALTON DIAGNOSTIC IMAGING CENTER LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
GARY MCMICHAEL (MEMBER)
(850) 862-7070
Entity
Organization
Contact information
Practice address
1112 HOSPITAL RD, SUITE C, FORT WALTON BEACH, FL 32547-6742
(850) 862-7070
(850) 862-0900
Mailing address
1112 HOSPITAL RD, SUITE C, FORT WALTON BEACH, FL 32547-6742
(850) 862-7070
(850) 862-0900
Taxonomy
Speciality
Code
Description
License number
State
261QM1300X
Multi-Specialty Clinic/Center
HCC4489
FL
261QR0200X
Radiology Clinic/Center
Primary
HCC4489
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
7732283
AETNA PROVIDER NO.
FL
01
—
V2837
BCBS FL PROVIDER NO.
FL
Enumeration date
05/19/2006
Last updated
09/11/2025
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