Provider Demographics
NPI:1598752149
Name:FLORENCE RADIOLOGICAL
Entity Type:Organization
Organization Name:FLORENCE RADIOLOGICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:L
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:843-669-5162
Mailing Address - Street 1:PO BOX 26869
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29616-1869
Mailing Address - Country:US
Mailing Address - Phone:800-707-7961
Mailing Address - Fax:865-766-8868
Practice Address - Street 1:555 E CHEVES ST
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29506-2617
Practice Address - Country:US
Practice Address - Phone:843-669-5162
Practice Address - Fax:843-667-4573
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-29
Last Update Date:2011-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2085B0100X, 2085N0700X, 2085N0904X, 2085P0229X, 2085R0202X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody ImagingGroup - Single Specialty
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiologyGroup - Single Specialty
No2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear RadiologyGroup - Single Specialty
No2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric RadiologyGroup - Single Specialty
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPA0748Medicaid
SCCA5357OtherRAILROAD MEDICARE
NC8901567Medicaid
NC8901567Medicaid
SCPA0748Medicaid
SC=========OtherSTANDARD TAX ID
SC=========OtherTRICARE
SC=========OtherFEDERAL BLACK LUNG
SC=========OtherUS DEPT OF LABOR
SCCA5357OtherRAILROAD MEDICARE
SC=========OtherFEDERAL BLACK LUNG