Basic Information
| Provider Information | |||||||||
| NPI: | 1972600385 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CORAL REEF RADIOLOGY ASSOCIATES PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 900 E PRIMA VISTA BLVD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | PORT ST LUCIE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349522366 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7726213000 | ||||||||
| FaxNumber: | 7726213181 | ||||||||
| Practice Location | |||||||||
| Address1: | 9333 SW 152ND ST | ||||||||
| Address2: | |||||||||
| City: | VILLAGE OF PALMETTO BAY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331571778 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7726213000 | ||||||||
| FaxNumber: | 7726213181 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2006 | ||||||||
| LastUpdateDate: | 07/29/2008 | ||||||||
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| AuthorizedOfficialLastName: | GREGG | ||||||||
| AuthorizedOfficialFirstName: | MITCHELL | ||||||||
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| AuthorizedOfficialTitleorPosition: | REGISTERED AGENT | ||||||||
| AuthorizedOfficialTelephone: | 7726213059 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 062960000 | 05 | FL | MEDICAID |