1912463258 NPI number — FLORIDA RADIOLOGY IMAGING AT LAKE MARY LLC

Table of content: (NPI 1912463258)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912463258 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 WINTER GARDEN
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:
1912463258
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/12/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
900 WINDERLEY PL STE 2100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MAITLAND
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32751-4191
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
407-200-1606
Provider Business Mailing Address Fax Number:
407-303-0893

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2200 FOWLER GROVE BLVD STE 60
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WINTER GARDEN
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34787-5597
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
407-200-0538
Provider Business Practice Location Address Fax Number:
407-614-0524
Provider Enumeration Date:
02/12/2019

Additional Information

Authorized Official

Authorized Official Last Name:
PETER
Authorized Official First Name:
HENDERSON
Authorized Official Middle Name:
Authorized Official Title or Position:
SENIOR DIRECTOR
Authorized Official Telephone Number:
407-200-2227

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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