Provider Demographics
NPI:1003983610
Name:FLORIDA RADIOLOGY IMAGING AT LAKE MARY LLC
Entity Type:Organization
Organization Name:FLORIDA RADIOLOGY IMAGING AT LAKE MARY LLC
Other - Org Name:FLORIDA RADIOLOGY IMAGING AT UNIVERSAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:REEVES
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:407-834-8722
Mailing Address - Street 1:PO BOX 150130
Mailing Address - Street 2:
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32715-0130
Mailing Address - Country:US
Mailing Address - Phone:407-767-5028
Mailing Address - Fax:407-767-8443
Practice Address - Street 1:6000 TURKEY LAKE RD
Practice Address - Street 2:SUITE 107
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32819-4200
Practice Address - Country:US
Practice Address - Phone:407-834-8722
Practice Address - Fax:407-834-5325
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FLORIDA RADIOLOGY IMAGING AT LAKE MARY LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-29
Last Update Date:2008-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiologyGroup - Single Specialty
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Single Specialty
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic UltrasoundGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLV3162OtherBCBS GROUP NUMBER
FLV3162OtherBCBS GROUP NUMBER