Basic Information
| Provider Information | |||||||||
| NPI: | 1285243394 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FLORIDA RADIOLOGY IMAGING AT LAKE MARY LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 900 WINDERLEY PL STE 2100 | ||||||||
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| City: | MAITLAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327514191 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4072002355 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2488 E IRLO BRONSON MEMORIAL HWY | ||||||||
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| City: | KISSIMMEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347444948 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4072005440 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2020 | ||||||||
| LastUpdateDate: | 07/24/2020 | ||||||||
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| AuthorizedOfficialLastName: | MAZERES | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4072002227 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 07/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.