Provider Demographics
NPI:1104219948
Name:PROFESSIONAL RADIOLOGY ASSOCIATES
Entity Type:Organization
Organization Name:PROFESSIONAL RADIOLOGY ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:A
Authorized Official - Last Name:HILL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-435-0723
Mailing Address - Street 1:29750 US 19 N
Mailing Address - Street 2:SUITE 205
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33761-1510
Mailing Address - Country:US
Mailing Address - Phone:352-435-0723
Mailing Address - Fax:352-435-0724
Practice Address - Street 1:212 N 2ND ST
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-5103
Practice Address - Country:US
Practice Address - Phone:352-435-0723
Practice Address - Fax:352-435-0724
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-17
Last Update Date:2015-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL728642085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty