Provider Demographics
NPI:1578503165
Name:PRESTIGE IMAGING LLC
Entity Type:Organization
Organization Name:PRESTIGE IMAGING LLC
Other - Org Name:PRESTIGE IMAGING AT UNIVERSITY GROVES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:JAY
Authorized Official - Last Name:LICHTENSTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:941-487-2550
Mailing Address - Street 1:PO BOX 919028
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32891-9028
Mailing Address - Country:US
Mailing Address - Phone:727-793-9300
Mailing Address - Fax:727-793-0052
Practice Address - Street 1:2415 UNIVERSITY PKWY
Practice Address - Street 2:UNIVERSITY HEALTH PARK, BUILING 3, SUITE 112
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34243-2809
Practice Address - Country:US
Practice Address - Phone:941-487-2130
Practice Address - Fax:941-487-2138
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-08
Last Update Date:2009-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLV3087OtherBCBS
FL273488500Medicaid
FLDE3457OtherRR MEDICARE
FLV3087OtherBCBS