Provider Demographics
NPI:1174299978
Name:RADIOLOGY REGIONAL CENTER, PA
Entity Type:Organization
Organization Name:RADIOLOGY REGIONAL CENTER, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:KRIVISKY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:239-936-2316
Mailing Address - Street 1:3660 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-8005
Mailing Address - Country:US
Mailing Address - Phone:239-936-2316
Mailing Address - Fax:239-834-6106
Practice Address - Street 1:9776 BONITA BEACH RD SE STE 100
Practice Address - Street 2:
Practice Address - City:BONITA SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34135-4773
Practice Address - Country:US
Practice Address - Phone:239-444-2200
Practice Address - Fax:239-444-2210
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-20
Last Update Date:2021-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL054636414Medicaid