Basic Information
| Provider Information | |||||||||
| NPI: | 1942389747 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FLORIDA RADIOLOGY IMAGING AT LAKE MARY LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ADVENTHEALTH IMAGING PRINCETON | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 900 WINDERLEY PL STE 2100 | ||||||||
| Address2: | |||||||||
| City: | MAITLAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327514191 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4077670433 | ||||||||
| FaxNumber: | 4073030893 | ||||||||
| Practice Location | |||||||||
| Address1: | 235 E PRINCETON ST | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328045553 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4077670433 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2006 | ||||||||
| LastUpdateDate: | 06/14/2019 | ||||||||
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| AuthorizedOfficialLastName: | FELSBERG | ||||||||
| AuthorizedOfficialFirstName: | GERY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4077670433 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FLORIDA RADIOLOGY IMAGING AT LAKE MARY LLC | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085B0100X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Body Imaging | 2085N0700X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology | 2085N0904X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Nuclear Radiology | 2085R0204X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2085U0001X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Ultrasound | 2085R0202X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | V2901 | 01 | FL | BCBS GRP-LOCATION | OTHER | 265644202 | 05 | FL | MEDICAID |