Provider Demographics
NPI:1508873647
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:33756-5945
Mailing Address - Country:US
Mailing Address - Phone:727-446-6760
Mailing Address - Fax:727-441-2465
Practice Address - Street 1:36463 US HIGHWAY 19 N
Practice Address - Street 2:
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34684-1329
Practice Address - Country:US
Practice Address - Phone:727-771-2795
Practice Address - Fax:727-786-7265
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLV2594OtherBC/BS PALM HBR, FL
FLE4187Medicare ID - Type Unspecified