Provider Demographics
NPI:1073790291
Name:CUSTOM RADIOLOGY SOLUTIONS LLC
Entity Type:Organization
Organization Name:CUSTOM RADIOLOGY SOLUTIONS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHAIM
Authorized Official - Middle Name:J
Authorized Official - Last Name:MARGOLIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:239-333-2484
Mailing Address - Street 1:13300-56 S. CLEVELAND AVE #305
Mailing Address - Street 2:PMB#239
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907
Mailing Address - Country:US
Mailing Address - Phone:239-333-2484
Mailing Address - Fax:239-333-2483
Practice Address - Street 1:13731 METROPOLIS AVE
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912
Practice Address - Country:US
Practice Address - Phone:239-333-2484
Practice Address - Fax:239-333-2483
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-30
Last Update Date:2011-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME623062085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME62306OtherMEDICAL LICENSE