Provider Demographics
NPI:1851414023
Name:FLORIDA RADIOLOGY IMAGING AT LAKE MARY LLC
Entity Type:Organization
Organization Name:FLORIDA RADIOLOGY IMAGING AT LAKE MARY LLC
Other - Org Name:FLORIDA RADIOLOGY IMAGING AT WATERFORD LAKES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:PEDRO
Authorized Official - Middle Name:
Authorized Official - Last Name:RODRIGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:407-949-6444
Mailing Address - Street 1:900 WINDERLEY PL STE 2100
Mailing Address - Street 2:
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-4191
Mailing Address - Country:US
Mailing Address - Phone:407-767-5028
Mailing Address - Fax:
Practice Address - Street 1:12301 LAKE UNDERHILL ROAD
Practice Address - Street 2:SUITE 103
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32828
Practice Address - Country:US
Practice Address - Phone:407-834-8722
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FLORIDA RADIOLOGY IMAGING AT LAKE MARY LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-04-10
Last Update Date:2019-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
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
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Single Specialty
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic UltrasoundGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1740256494OtherNPI BASE FOR GROUP
FL2656442 04Medicaid