Basic Information
Provider Information | |||||||||
NPI: | 1285627265 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FLOREA | ||||||||
FirstName: | RADIAN | ||||||||
MiddleName: | I | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 100 GROSS CRESCENT CIR | ||||||||
Address2: |   | ||||||||
City: | FT OGLETHORPE | ||||||||
State: | GA | ||||||||
PostalCode: | 307423643 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7068582101 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2525 DESALES AVE | ||||||||
Address2: |   | ||||||||
City: | CHATTANOOGA | ||||||||
State: | TN | ||||||||
PostalCode: | 374041161 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4234957404 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/25/2005 | ||||||||
LastUpdateDate: | 11/02/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 049171 | GA | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207R00000X | 41259 | TN | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 00895881B | 05 | GA |   | MEDICAID | 7622393 | 01 | GA | AETNA | OTHER | 4084448 | 01 | TN | BCBS OF TENNESSEE | OTHER | 52676663 | 01 | GA | BCBS OF GEORGIA | OTHER |