1669744801 NPI number — RADIOLOGY & IMAGING SPECIALISTS OF LAKELAND, PA

Table of content: (NPI 1669744801)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669744801 NPI number — RADIOLOGY & IMAGING SPECIALISTS OF LAKELAND, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RADIOLOGY & IMAGING SPECIALISTS OF LAKELAND, 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:
6
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:
1669744801
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/08/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2115 CRYSTAL GROVE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKELAND
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33801-6875
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
863-688-2334
Provider Business Mailing Address Fax Number:
863-577-1160

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
206 W ALEXANDER ST
Provider Second Line Business Practice Location Address:
STE 1
Provider Business Practice Location Address City Name:
PLANT CITY
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33563-7100
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
863-688-2334
Provider Business Practice Location Address Fax Number:
863-577-1160
Provider Enumeration Date:
02/03/2012

Additional Information

Authorized Official

Authorized Official Last Name:
SORRELLS
Authorized Official First Name:
RICHARD
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
863-688-2334

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: V2720 . This is a "BCBS FL" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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