Basic Information
| Provider Information | |||||||||
| NPI: | 1194379743 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TOWER IMAGING LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | TOWER RADIOLOGY CENTER TRINITY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2700 UNIVERSITY SQUARE DRIVE | ||||||||
| Address2: | TOWER IMAGING INC | ||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336125513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8132532721 | ||||||||
| FaxNumber: | 8132532299 | ||||||||
| Practice Location | |||||||||
| Address1: | 2115 LITTLE RD | ||||||||
| Address2: | |||||||||
| City: | TRINITY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346554410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7278475122 | ||||||||
| FaxNumber: | 7278468549 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2019 | ||||||||
| LastUpdateDate: | 02/01/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | POWERS | ||||||||
| AuthorizedOfficialFirstName: | BEVERLY | ||||||||
| AuthorizedOfficialMiddleName: | CHAPMAN | ||||||||
| AuthorizedOfficialTitleorPosition: | PROVIDER ENROLLMENT SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 8132532721 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | TOWER IMAGING LLC | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085U0001X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Ultrasound | 2085R0202X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 043166420 | 05 | FL | MEDICAID |