Basic Information
| Provider Information | |||||||||
| NPI: | 1912406984 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RADIOLOGY & IMAGING SPECIALISTS OF LAKELAND PA | ||||||||
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| OtherOrganizationName: | LAKELAND VASCULAR INSTITUTE OUTPATIENT CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2125 CRYSTAL GROVE DR | ||||||||
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| City: | LAKELAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338016875 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8635770303 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3221 S FLORIDA AVE STE B | ||||||||
| Address2: | |||||||||
| City: | LAKELAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338034550 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8635770296 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/06/2018 | ||||||||
| LastUpdateDate: | 02/06/2018 | ||||||||
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| AuthorizedOfficialLastName: | GOODEMOTE | ||||||||
| AuthorizedOfficialFirstName: | EDWARD | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8635770303 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0200X | N | Ambulatory Health Care Facilities | Clinic/Center | Radiology | 2085R0204X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology |
No ID Information.