Provider Demographics
NPI:1437615770
Name:FLORIDA RADIOLOGY IMAGING AT LAKE MARY, LLC
Entity Type:Organization
Organization Name:FLORIDA RADIOLOGY IMAGING AT LAKE MARY, LLC
Other - Org Name:ADVENTHEALTH IMAGING ALTAMONTE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP/CFO
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:MAZERES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-200-5403
Mailing Address - Street 1:900 WINDERLEY PL STE 2100
Mailing Address - Street 2:
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-4191
Mailing Address - Country:US
Mailing Address - Phone:407-303-2155
Mailing Address - Fax:407-303-2165
Practice Address - Street 1:661 E ALTAMONTE DR STE 130
Practice Address - Street 2:
Practice Address - City:ALTAMONTE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32701-5102
Practice Address - Country:US
Practice Address - Phone:407-303-2155
Practice Address - Fax:407-303-2165
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FLORIDA RADIOLOGY IMAGING AT LAKE MARY, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-02-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty