Basic Information
| Provider Information | |||||||||
| NPI: | 1063032993 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RADIOLOGY & IMAGING SPECIALISTS OF LAKELAND, PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2125 CRYSTAL GROVE DR | ||||||||
| Address2: | |||||||||
| City: | LAKELAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338016875 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8635770303 | ||||||||
| FaxNumber: | 8635770301 | ||||||||
| Practice Location | |||||||||
| Address1: | 1417 LAKELAND HILLS BLVD STE 104 | ||||||||
| Address2: | |||||||||
| City: | LAKELAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338053200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8636882334 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/21/2020 | ||||||||
| LastUpdateDate: | 04/21/2020 | ||||||||
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| AuthorizedOfficialLastName: | VOLLMER | ||||||||
| AuthorizedOfficialFirstName: | JOYCE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 8635770303 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 04/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2086S0129X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery | 2085R0204X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology |
No ID Information.