Provider Demographics
NPI:1629294681
Name:PHYSICIANS IMAGING-MT DORA LLC
Entity Type:Organization
Organization Name:PHYSICIANS IMAGING-MT DORA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATING MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:ELIAS
Authorized Official - Middle Name:J
Authorized Official - Last Name:GERTH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:305-295-1242
Mailing Address - Street 1:P.O. BOX 4610
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70606-4610
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3615 LAKE CENTER DR
Practice Address - Street 2:
Practice Address - City:MOUNT DORA
Practice Address - State:FL
Practice Address - Zip Code:32757-2364
Practice Address - Country:US
Practice Address - Phone:352-383-3716
Practice Address - Fax:352-383-7457
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-18
Last Update Date:2007-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology