Provider Demographics
NPI:1114247053
Name:CLEVELAND RADIOLOGY CENTER INC
Entity Type:Organization
Organization Name:CLEVELAND RADIOLOGY CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARIO
Authorized Official - Middle Name:
Authorized Official - Last Name:FONSECA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-775-9986
Mailing Address - Street 1:12995 S CLEVELAND AVE STE 182
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-7719
Mailing Address - Country:US
Mailing Address - Phone:305-775-9986
Mailing Address - Fax:
Practice Address - Street 1:12995 S CLEVELAND AVE STE 182
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-7719
Practice Address - Country:US
Practice Address - Phone:305-775-9986
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-02
Last Update Date:2010-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)
No261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology