Basic Information
| Provider Information | |||||||||
| NPI: | 1942534672 | ||||||||
| 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: | |||||||||
| Practice Location | |||||||||
| Address1: | 572 OCOEE COMMERCE PARKWAY | ||||||||
| Address2: | |||||||||
| City: | OCOEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 34761 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4072286635 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2009 | ||||||||
| LastUpdateDate: | 10/21/2009 | ||||||||
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| AuthorizedOfficialLastName: | ABOUD | ||||||||
| AuthorizedOfficialFirstName: | ANTHONY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | C.E.O. | ||||||||
| AuthorizedOfficialTelephone: | 4072286635 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | D.O. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Radiology |
ID Information
| ID | Type | State | Issuer | Description | E4187 | 01 | FL | MEDICARE PTAN | OTHER |