Provider Demographics
NPI:1740256494
Name:FLORIDA RADIOLOGY IMAGING AT LAKE MARY, LLC
Entity type:Organization
Organization Name:FLORIDA RADIOLOGY IMAGING AT LAKE MARY, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:COO/VP
Authorized Official - Prefix:
Authorized Official - First Name:RACHNA
Authorized Official - Middle Name:
Authorized Official - Last Name:ATWAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-200-4658
Mailing Address - Street 1:900 HOPE WAY
Mailing Address - Street 2:
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32714-1502
Mailing Address - Country:US
Mailing Address - Phone:407-200-2355
Mailing Address - Fax:407-767-0608
Practice Address - Street 1:960 RINEHART RD STE 1000
Practice Address - Street 2:
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-1561
Practice Address - Country:US
Practice Address - Phone:855-241-2455
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-23
Last Update Date:2024-11-08
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
No2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric RadiologyGroup - Single Specialty
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Single Specialty
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic UltrasoundGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLV2517OtherBCBS LK MARY
FL265644200Medicaid
CK2813OtherRR MEDIARE - GROUP NUMBER
FL34329Medicare ID - Type UnspecifiedGROUP NUMBER