Basic Information
| Provider Information | |||||||||
| NPI: | 1114673662 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INTELLIRAD IMAGING, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7623 | ||||||||
| Address2: | |||||||||
| City: | NAPLES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 341017623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004753698 | ||||||||
| FaxNumber: | 9856460750 | ||||||||
| Practice Location | |||||||||
| Address1: | 3476 S UNIVERSITY DR | ||||||||
| Address2: | |||||||||
| City: | DAVIE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333282000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9544754350 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2022 | ||||||||
| LastUpdateDate: | 07/05/2022 | ||||||||
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| AuthorizedOfficialLastName: | JOSEPH | ||||||||
| AuthorizedOfficialFirstName: | RONALD | ||||||||
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| AuthorizedOfficialTitleorPosition: | TREASURER | ||||||||
| AuthorizedOfficialTelephone: | 3057127229 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | INTELLIRAD IMAGING, LLC | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 07/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.