Basic Information
| Provider Information | |||||||||
| NPI: | 1144289539 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PANCHOLY | ||||||||
| FirstName: | AJAY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2700 UNIVERSITY SQUARE DRIVE | ||||||||
| Address2: | RADIOLOGY ASSOCIATES OF TAMPA | ||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336125513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8132515822 | ||||||||
| FaxNumber: | 8132544597 | ||||||||
| Practice Location | |||||||||
| Address1: | 2700 UNIVERSITY SQUARE DRIVE | ||||||||
| Address2: | RADIOLOGY ASSOCIATES OF TAMPA | ||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336125513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8132515822 | ||||||||
| FaxNumber: | 8132544597 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2006 | ||||||||
| LastUpdateDate: | 02/16/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085N0700X | ME89899 | FL | N | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology | 2085R0202X | ME89899 | FL | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 118717 | 05 | AL | MEDICAID | 271833200 | 05 | FL | MEDICAID |