Basic Information
| Provider Information | |||||||||
| NPI: | 1417953852 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WEST FLORIDA PET SERVICES LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 427 SOUTH PARSONS AVE | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | BRANDON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335115980 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8133152080 | ||||||||
| FaxNumber: | 8133152090 | ||||||||
| Practice Location | |||||||||
| Address1: | 427 SOUTH PARSONS AVE | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | BRANDON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335115980 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8133152080 | ||||||||
| FaxNumber: | 8133152090 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2005 | ||||||||
| LastUpdateDate: | 08/31/2011 | ||||||||
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| AuthorizedOfficialLastName: | RUTHERFORD | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | B. | ||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR VP | ||||||||
| AuthorizedOfficialTelephone: | 6153092190 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1200X | N | Ambulatory Health Care Facilities | Clinic/Center | Magnetic Resonance Imaging (MRI) | 261QR0200X | N | Ambulatory Health Care Facilities | Clinic/Center | Radiology | 261QR0206X | N | Ambulatory Health Care Facilities | Clinic/Center | Radiology, Mammography | 261QR0207X | N | Ambulatory Health Care Facilities | Clinic/Center | Radiology, Mobile Mammography | 261QR0208X | Y | Ambulatory Health Care Facilities | Clinic/Center | Radiology, Mobile |
ID Information
| ID | Type | State | Issuer | Description | V3345 | 01 | FL | BCBS OF FL | OTHER |