Provider Demographics
NPI:1467499863
Name:BLOOMINGDALE RADIOLOGY CORP
Entity Type:Organization
Organization Name:BLOOMINGDALE RADIOLOGY CORP
Other - Org Name:BLOOMINGDALE RADIOLOGY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:G
Authorized Official - Last Name:WINTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-463-8256
Mailing Address - Street 1:PO BOX 931083
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:31193-1083
Mailing Address - Country:US
Mailing Address - Phone:772-600-0324
Mailing Address - Fax:772-600-0327
Practice Address - Street 1:3350 BELL SHOALS RD
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-7637
Practice Address - Country:US
Practice Address - Phone:813-654-4883
Practice Address - Fax:813-676-0339
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLHCC3759261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU1125Medicare ID - Type UnspecifiedFL MEDICARE