Provider Demographics
NPI:1629262266
Name:TRIAD RADIOLOGY LLC
Entity Type:Organization
Organization Name:TRIAD RADIOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MILES
Authorized Official - Middle Name:E
Authorized Official - Last Name:GILMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-665-1197
Mailing Address - Street 1:329 E OLYMPIA AVE
Mailing Address - Street 2:
Mailing Address - City:PUNTA GORDA
Mailing Address - State:FL
Mailing Address - Zip Code:33950-3833
Mailing Address - Country:US
Mailing Address - Phone:941-637-9729
Mailing Address - Fax:941-637-3873
Practice Address - Street 1:1500 LEE BLVD
Practice Address - Street 2:
Practice Address - City:LEHIGH ACRES
Practice Address - State:FL
Practice Address - Zip Code:33936-4835
Practice Address - Country:US
Practice Address - Phone:239-368-4710
Practice Address - Fax:941-637-3873
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-28
Last Update Date:2008-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL98264OtherBCBSFL
FLAH316Medicare PIN