1104601038 NPI number — RADIOLOGY IMAGING ASSOCIATES LLC

Table of content: (NPI 1104601038)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104601038 NPI number — RADIOLOGY IMAGING ASSOCIATES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RADIOLOGY IMAGING ASSOCIATES 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:
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:
1104601038
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/29/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 21643
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TAMPA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33622-1643
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:
101 HEALTH PARK BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ST AUGUSTINE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32086-5777
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-819-4707
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/29/2023

Additional Information

Authorized Official

Authorized Official Last Name:
RIVERA
Authorized Official First Name:
CALEB
Authorized Official Middle Name:
RUBEN
Authorized Official Title or Position:
MD
Authorized Official Telephone Number:
352-671-4221

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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