Provider Demographics
NPI:1942495916
Name:INTERVASC AT BAY RADIOLOGY, LLC
Entity Type:Organization
Organization Name:INTERVASC AT BAY RADIOLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:LLOYD
Authorized Official - Middle Name:G
Authorized Official - Last Name:LOGUE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:850-747-4905
Mailing Address - Street 1:PO BOX 1770
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32402-1770
Mailing Address - Country:US
Mailing Address - Phone:850-747-4905
Mailing Address - Fax:850-747-4907
Practice Address - Street 1:527 N. PALO ALTO AVE.
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32401-3639
Practice Address - Country:US
Practice Address - Phone:850-873-3990
Practice Address - Fax:850-873-3974
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BAY RADIOLOGY ASSOCIATES, PL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-09-12
Last Update Date:2014-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL279907300Medicaid
FL98028OtherBCBS
FLAG442Medicare PIN