1225015357 NPI number — PRESGAR IMAGING OF ROCKLEDGE LLC

Table of content: (NPI 1225015357)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225015357 NPI number — PRESGAR IMAGING OF ROCKLEDGE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRESGAR IMAGING OF ROCKLEDGE LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
OPEN MRI OF ROCKLEDGE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1225015357
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/28/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
23110 STATE RD 54
Provider Second Line Business Mailing Address:
PMB 292
Provider Business Mailing Address City Name:
LUTZ
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33549-2921
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
352-578-2055
Provider Business Mailing Address Fax Number:
813-971-0818

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1978 ROCKLEDGE BLVD
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
ROCKLEDGE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32955-3722
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
321-633-1600
Provider Business Practice Location Address Fax Number:
321-633-0433
Provider Enumeration Date:
12/29/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
ROBERTSON
Authorized Official First Name:
ROBBIE
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT AND CEO
Authorized Official Telephone Number:
813-323-2594

Provider Taxonomy Codes

  • Taxonomy code: 261QM1200X , with the licence number:  HCC5110 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: CG5418 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 257947200 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".