Basic Information
| Provider Information | |||||||||
| NPI: | 1477560514 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SRA VENTURES INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | WESTCOAST RADIOLOGY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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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: | 1193 BLACKWOOD AVE | ||||||||
| Address2: | UNIT H | ||||||||
| City: | OCOEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347614518 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4076566040 | ||||||||
| FaxNumber: | 4076564431 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2006 | ||||||||
| LastUpdateDate: | 07/27/2012 | ||||||||
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| AuthorizedOfficialLastName: | ABOUD | ||||||||
| AuthorizedOfficialFirstName: | ANTHONY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7274466760 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DO | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0200X | FL | Y | Ambulatory Health Care Facilities | Clinic/Center | Radiology |
ID Information
| ID | Type | State | Issuer | Description | V3014 | 01 | FL | BC/BS OCOEE, FL | OTHER |