1003208620 NPI number — FLORIDA RADIOLOGY IMAGING AT LAKE MARY, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003208620 NPI number — FLORIDA RADIOLOGY IMAGING AT LAKE MARY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FLORIDA RADIOLOGY IMAGING AT LAKE MARY, 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:
ADVENTHEALTH IMAGING LAKE NONA
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:
1003208620
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/11/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9975 TAVISTOCK LAKES BLVD
Provider Second Line Business Mailing Address:
SUITE 120
Provider Business Mailing Address City Name:
ORLANDO
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32827-7559
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9975 TAVISTOCK LAKES BLVD
Provider Second Line Business Practice Location Address:
SUITE 120
Provider Business Practice Location Address City Name:
ORLANDO
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32827-7559
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
407-200-2865
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/19/2015

Additional Information

Authorized Official

Authorized Official Last Name:
WYLIE
Authorized Official First Name:
WARREN
Authorized Official Middle Name:
Authorized Official Title or Position:
VP RADIOLOGY ENTERPRISE
Authorized Official Telephone Number:
407-303-3358

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)





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