Basic Information
| Provider Information | |||||||||
| NPI: | 1982605291 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RADIOLOGY PHYSICIANS OF INDIAN RIVER COUNTY LC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3725 11TH CIRCLE | ||||||||
| Address2: | |||||||||
| City: | VERO BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329604804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7725620163 | ||||||||
| FaxNumber: | 7725675631 | ||||||||
| Practice Location | |||||||||
| Address1: | 3725 11TH CIRCLE | ||||||||
| Address2: | |||||||||
| City: | VERO BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329604804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7725620163 | ||||||||
| FaxNumber: | 7725675631 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2005 | ||||||||
| LastUpdateDate: | 01/13/2010 | ||||||||
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| AuthorizedOfficialLastName: | DION | ||||||||
| AuthorizedOfficialFirstName: | DONNA | ||||||||
| AuthorizedOfficialMiddleName: | H | ||||||||
| AuthorizedOfficialTitleorPosition: | BUSINESS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7724100155 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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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 | 038000800 | 05 | FL | MEDICAID | K4539 | 01 | FL | BLUE CROSS/BLUE SHIELD | OTHER |