Basic Information
| Provider Information | |||||||||
| NPI: | 1568749786 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PROFESSIONAL RADIOLOGY ASSOCIATES, PA | ||||||||
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| OtherOrganizationName: | ADVANCED IMAGING | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 W MAIN ST | ||||||||
| Address2: | SUITE 108 | ||||||||
| City: | BABYLON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117023027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6319305215 | ||||||||
| FaxNumber: | 6315178007 | ||||||||
| Practice Location | |||||||||
| Address1: | 1639 N VOLUSIA AVE | ||||||||
| Address2: | |||||||||
| City: | ORANGE CITY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327633843 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3867747226 | ||||||||
| FaxNumber: | 6315178007 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2011 | ||||||||
| LastUpdateDate: | 01/17/2013 | ||||||||
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| AuthorizedOfficialLastName: | LORD | ||||||||
| AuthorizedOfficialFirstName: | JAYSON | ||||||||
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| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3524350723 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 261QR0200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Radiology |
ID Information
| ID | Type | State | Issuer | Description | 007181000 | 05 | FL | MEDICAID |