Basic Information
| Provider Information | |||||||||
| NPI: | 1558528513 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTH BAY HOSPITAL OUTPATIENT DIAGNOSTIC/IMAGING CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SOUTH BAY IMAGING LLC | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 22607 | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336222607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8138996220 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4051 UPPER CREEK DR | ||||||||
| Address2: | |||||||||
| City: | SUN CITY CENTER | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335736825 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8136348329 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2008 | ||||||||
| LastUpdateDate: | 05/19/2008 | ||||||||
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| AuthorizedOfficialLastName: | NORSOP | ||||||||
| AuthorizedOfficialFirstName: | ELLIS | ||||||||
| AuthorizedOfficialMiddleName: | B. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8138996220 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 171863 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 171863 | 01 | FL | LICENSE # | OTHER |