1174299978 NPI number — RADIOLOGY REGIONAL CENTER, PA

Table of content: EDWARD JOSEPH LIS RPH (NPI 1699097220)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174299978 NPI number — RADIOLOGY REGIONAL CENTER, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RADIOLOGY REGIONAL CENTER, PA
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:
Provider Other Organization Name Type Code:
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:
1174299978
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/20/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3660 BROADWAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT MYERS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33901-8005
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
239-936-2316
Provider Business Mailing Address Fax Number:
239-834-6106

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9776 BONITA BEACH RD SE STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BONITA SPRINGS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34135-4773
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
239-444-2200
Provider Business Practice Location Address Fax Number:
239-444-2210
Provider Enumeration Date:
08/20/2021

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
KRIVISKY
Authorized Official First Name:
BRIAN
Authorized Official Middle Name:
A
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
239-936-2316

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 054636414 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".