Provider Demographics
NPI:1720536154
Name:SUMMERLIN IMAGING CENTER LLC
Entity Type:Organization
Organization Name:SUMMERLIN IMAGING CENTER LLC
Other - Org Name:PARK AVENUE IMAGING
Other - Org Type:Other Name
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:BRADFORD
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-331-0808
Mailing Address - Street 1:6415 LAKE WORTH RD STE 102
Mailing Address - Street 2:
Mailing Address - City:GREENACRES
Mailing Address - State:FL
Mailing Address - Zip Code:33463-3009
Mailing Address - Country:US
Mailing Address - Phone:561-331-0808
Mailing Address - Fax:561-237-6034
Practice Address - Street 1:2128 PARK AVE
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073
Practice Address - Country:US
Practice Address - Phone:904-375-8884
Practice Address - Fax:904-375-8887
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-14
Last Update Date:2020-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLHCC10650OtherAHCC LICENSE