1407104631 NPI number — SHERIDAN RADIOLOGY SERVICES OF SOUTH FLORIDA, INC

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 1407104631 NPI number — SHERIDAN RADIOLOGY SERVICES OF SOUTH FLORIDA, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SHERIDAN RADIOLOGY SERVICES OF SOUTH FLORIDA, INC
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:
1407104631
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/08/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
02/10/2023
NPI Reactivation Date:
11/08/2023

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 452095
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SUNRISE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33345-2095
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:
5405 OKEECHOBEE BLVD STE 101
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WEST PALM BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33417-4544
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
561-697-3001
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/20/2012

Additional Information

Authorized Official

Authorized Official Last Name:
KONDAS
Authorized Official First Name:
KATHY
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICER
Authorized Official Telephone Number:
973-251-1122

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: 000318143 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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