Provider Demographics
NPI:1235401480
Name:RADIOLOGY & IMAGING SPECIALISTS OF LAKELAND, PA
Entity Type:Organization
Organization Name:RADIOLOGY & IMAGING SPECIALISTS OF LAKELAND, PA
Other - Org Name:SOUTHSIDE OFFICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:J
Authorized Official - Last Name:GOODEMOTE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, RN
Authorized Official - Phone:863-577-0303
Mailing Address - Street 1:2125 CRYSTAL GROVE DR
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33801-6875
Mailing Address - Country:US
Mailing Address - Phone:866-804-7649
Mailing Address - Fax:614-764-9147
Practice Address - Street 1:3021 LAKELAND HIGHLANDS RD
Practice Address - Street 2:STE 3
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33803-4339
Practice Address - Country:US
Practice Address - Phone:863-688-2334
Practice Address - Fax:863-577-1167
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RADIOLOGY & IMAGING SPECIALISTS OF LAKELAND, PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-02-03
Last Update Date:2016-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLV0068OtherBCBS FL