Provider Demographics
NPI:1144210477
Name:LAD IMAGING LLC
Entity Type:Organization
Organization Name:LAD IMAGING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR VP
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:B
Authorized Official - Last Name:RUTHERFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-309-2190
Mailing Address - Street 1:1555 SAXON BLVD
Mailing Address - Street 2:STE 401
Mailing Address - City:DELTONA
Mailing Address - State:FL
Mailing Address - Zip Code:32725-5861
Mailing Address - Country:US
Mailing Address - Phone:386-532-0094
Mailing Address - Fax:386-532-0451
Practice Address - Street 1:1555 SAXON BLVD
Practice Address - Street 2:STE 401
Practice Address - City:DELTONA
Practice Address - State:FL
Practice Address - Zip Code:32725-5861
Practice Address - Country:US
Practice Address - Phone:386-532-0094
Practice Address - Fax:386-532-0451
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-27
Last Update Date:2011-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
No261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)
No261QR0206XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mammography
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL280837400Medicaid
FLV3036OtherBCBS OF FL
FLU4445Medicare PIN