Provider Demographics
NPI:1508869405
Name:GAINESVILLE RADIOLOGY GROUP WEST, LLC
Entity Type:Organization
Organization Name:GAINESVILLE RADIOLOGY GROUP WEST, LLC
Other - Org Name:PUTNAM RADIOLOGY GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:TONY
Authorized Official - Middle Name:
Authorized Official - Last Name:ARVESU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-332-2040
Mailing Address - Street 1:4960 W NEWBERRY RD
Mailing Address - Street 2:STE 280
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32607-2201
Mailing Address - Country:US
Mailing Address - Phone:352-371-3336
Mailing Address - Fax:352-371-3372
Practice Address - Street 1:4960 W NEWBERRY RD
Practice Address - Street 2:STE 280
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32607-2201
Practice Address - Country:US
Practice Address - Phone:352-371-3336
Practice Address - Fax:352-371-3372
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2561762085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLV3013OtherBCBS IDTF NUMBER EAST OFC
FLV2766OtherBCBS IDTF NUMBER
FL45280Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER
FLE4432Medicare ID - Type UnspecifiedIDTF NUMBER