Provider Demographics
NPI:1891874699
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 OVIEDO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:
Authorized Official - Last Name:BERGER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:407-767-0433
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 1:8000 RED BUG LAKE RD
Practice Address - Street 2:SUITE 120
Practice Address - City:OVIEDO
Practice Address - State:FL
Practice Address - Zip Code:32765-9226
Practice Address - Country:US
Practice Address - Phone:407-767-0433
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FLORIDA RADIOLOGY IMAGING AT LAKE MARY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-03
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
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Single Specialty
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic UltrasoundGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL265644201Medicaid
FLV2787OtherBCBS GROUP # FOR LOCATION