Basic Information
| Provider Information | |||||||||
| NPI: | 1326378951 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CENTRAL FLORIDA IMAGING ASSOCIATES, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 23027 | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336233027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8138996220 | ||||||||
| FaxNumber: | 8139858006 | ||||||||
| Practice Location | |||||||||
| Address1: | 410 11TH STREET | ||||||||
| Address2: | |||||||||
| City: | LAKE WALES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338534203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8636782761 | ||||||||
| FaxNumber: | 8139858006 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2010 | ||||||||
| LastUpdateDate: | 03/26/2015 | ||||||||
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| AuthorizedOfficialLastName: | NORSOPH | ||||||||
| AuthorizedOfficialFirstName: | ELLIS | ||||||||
| AuthorizedOfficialMiddleName: | B. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 8138996220 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0204X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2085B0100X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Body Imaging | 2085N0700X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology | 2085R0202X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 4007 | 01 | FL | STATE LICENSE NUMBER | OTHER | 001844600 | 05 | FL | MEDICAID |