Basic Information
| Provider Information | |||||||||
| NPI: | 1295069672 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SRA VENTURES INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | WESTCOAST RADIOLOGY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 501 S LINCOLN AVE | ||||||||
| Address2: | #15 | ||||||||
| City: | CLEARWATER | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337565945 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7274466760 | ||||||||
| FaxNumber: | 7274412465 | ||||||||
| Practice Location | |||||||||
| Address1: | 2040 SHORT AVE | ||||||||
| Address2: | #103 | ||||||||
| City: | ODESSA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335563445 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7278351450 | ||||||||
| FaxNumber: | 7278351470 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/01/2009 | ||||||||
| LastUpdateDate: | 04/08/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ABOUD | ||||||||
| AuthorizedOfficialFirstName: | ANTHONY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | C.E.O. | ||||||||
| AuthorizedOfficialTelephone: | 7278351450 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | D.O. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Radiology |
ID Information
| ID | Type | State | Issuer | Description | E4187 | 01 | FL | MEDICARE PTAN | OTHER |