Provider Demographics
NPI:1205829934
Name:SRA VENTURES INC
Entity Type:Organization
Organization Name:SRA VENTURES INC
Other - Org Name:WESTCOAST RADIOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:
Authorized Official - Last Name:ABOUD
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:727-446-6760
Mailing Address - Street 1:501 S LINCOLN AVE
Mailing Address - Street 2:#15
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33756-5901
Mailing Address - Country:US
Mailing Address - Phone:727-446-6760
Mailing Address - Fax:727-441-2465
Practice Address - Street 1:501 S LINCOLN AVE
Practice Address - Street 2:#15
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33756-5945
Practice Address - Country:US
Practice Address - Phone:727-446-6760
Practice Address - Fax:727-441-2465
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SRA VENTURES INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-08-29
Last Update Date:2012-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QM1200X, 261QR0206X
FLHCC2621261QR0200X
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
E4187Medicare ID - Type Unspecified