Basic Information
| Provider Information | |||||||||
| NPI: | 1427049931 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RADIOLOGY & IMAGING SPECIALISTS OF LAKELAND | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 20027 | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336220027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8668047649 | ||||||||
| FaxNumber: | 6147649147 | ||||||||
| Practice Location | |||||||||
| Address1: | 2125 CRYSTAL GROVE DR | ||||||||
| Address2: | |||||||||
| City: | LAKELAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338016875 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8636882334 | ||||||||
| FaxNumber: | 8635770301 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2005 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | GOODEMOTE | ||||||||
| AuthorizedOfficialFirstName: | EDWARD | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8636882334 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | PHD, RN | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 045292107 | 05 | FL | MEDICAID | 045292104 | 05 | FL | MEDICAID | 045292105 | 05 | FL | MEDICAID | 00584 | 01 | FL | BCBS OF FLORIDA | OTHER | 045292103 | 05 | FL | MEDICAID | CC6469 | 01 | FL | RR MEDICARE | OTHER | 045292101 | 05 | FL | MEDICAID | 045292100 | 05 | FL | MEDICAID | 045292106 | 05 | FL | MEDICAID |