Provider Demographics
NPI:1710215728
Name:FAWCETT IMAGING PORT CHARLOTTE PA
Entity Type:Organization
Organization Name:FAWCETT IMAGING PORT CHARLOTTE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RAMANAN
Authorized Official - Middle Name:
Authorized Official - Last Name:VENKAT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:810-230-9215
Mailing Address - Street 1:2325 STONEBRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48532-5407
Mailing Address - Country:US
Mailing Address - Phone:810-230-9215
Mailing Address - Fax:810-230-9225
Practice Address - Street 1:21298 OLEAN BLVD
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-6705
Practice Address - Country:US
Practice Address - Phone:810-230-9215
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-02
Last Update Date:2009-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty