Provider Demographics
NPI:1972600385
Name:CORAL REEF RADIOLOGY ASSOCIATES PA
Entity Type:Organization
Organization Name:CORAL REEF RADIOLOGY ASSOCIATES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED AGENT
Authorized Official - Prefix:
Authorized Official - First Name:MITCHELL
Authorized Official - Middle Name:
Authorized Official - Last Name:GREGG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:772-621-3059
Mailing Address - Street 1:900 E PRIMA VISTA BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-2366
Mailing Address - Country:US
Mailing Address - Phone:772-621-3000
Mailing Address - Fax:772-621-3181
Practice Address - Street 1:9333 SW 152ND ST
Practice Address - Street 2:
Practice Address - City:VILLAGE OF PALMETTO BAY
Practice Address - State:FL
Practice Address - Zip Code:33157-1778
Practice Address - Country:US
Practice Address - Phone:772-621-3000
Practice Address - Fax:772-621-3181
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2008-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL062960000Medicaid
FL99098Medicare ID - Type Unspecified