Provider Demographics
NPI:1154450351
Name:ADVANCE TECHNOLOGICAL RADIOLOGY, PA
Entity Type:Organization
Organization Name:ADVANCE TECHNOLOGICAL RADIOLOGY, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:T
Authorized Official - Last Name:ROSA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:863-421-9393
Mailing Address - Street 1:P.O. BOX 2159
Mailing Address - Street 2:
Mailing Address - City:HAINES CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33845-2159
Mailing Address - Country:US
Mailing Address - Phone:863-421-9393
Mailing Address - Fax:866-560-1517
Practice Address - Street 1:2235 NORTH BOULEVARD WEST
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:FL
Practice Address - Zip Code:33837-8990
Practice Address - Country:US
Practice Address - Phone:863-421-9393
Practice Address - Fax:866-560-1517
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-05
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL255768100Medicaid
FL255768100Medicaid