Provider Demographics
NPI:1043416928
Name:HEATHROW IMAGING LLC
Entity Type:Organization
Organization Name:HEATHROW IMAGING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:LAVELLE
Authorized Official - Middle Name:R
Authorized Official - Last Name:HARDIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-344-8203
Mailing Address - Street 1:1343 SOUTH INTERNATIONAL PARKWAY
Mailing Address - Street 2:SUITE 1351 BLDG 3
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-1401
Mailing Address - Country:US
Mailing Address - Phone:407-333-4464
Mailing Address - Fax:407-333-4393
Practice Address - Street 1:1343 SOUTH INTERNATIONAL PARKWAY
Practice Address - Street 2:SUITE 1351 BLDG 3
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-1401
Practice Address - Country:US
Practice Address - Phone:407-333-4464
Practice Address - Fax:407-333-4393
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-26
Last Update Date:2009-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001115600Medicaid
FLV3203OtherBCBS OF FL
FLDN3311OtherRR MEDICARE
FLDN3311OtherRR MEDICARE