Basic Information
Provider Information | |||||||||
NPI: | 1396724654 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | WEST FLORIDA RADIOLOGY ASSOCIATES, P.A. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 6478 HIGHWAY 90 | ||||||||
Address2: | SUITE D | ||||||||
City: | MILTON | ||||||||
State: | FL | ||||||||
PostalCode: | 325704560 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8505641030 | ||||||||
FaxNumber: | 8505641039 | ||||||||
Practice Location | |||||||||
Address1: | 6002 BERRYHILL RD | ||||||||
Address2: |   | ||||||||
City: | MILTON | ||||||||
State: | FL | ||||||||
PostalCode: | 325705062 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8506267762 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/13/2006 | ||||||||
LastUpdateDate: | 02/09/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HAMBLEY | ||||||||
AuthorizedOfficialFirstName: | PATRICIA | ||||||||
AuthorizedOfficialMiddleName: | S. | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 8505641030 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
ID | Type | State | Issuer | Description | 054828600 | 05 | FL |   | MEDICAID |