Provider Demographics
NPI:1811994551
Name:ULTRA IMAGING OF TAMPA LLC
Entity type:Organization
Organization Name:ULTRA IMAGING OF TAMPA LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:LAVELLE
Authorized Official - Middle Name:R
Authorized Official - Last Name:HARDIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-344-8203
Mailing Address - Street 1:2946 LAKELAND HIGHLANDS RD
Mailing Address - Street 2:HIGHLANDS PLAZA
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33803-4379
Mailing Address - Country:US
Mailing Address - Phone:863-583-1674
Mailing Address - Fax:863-583-1678
Practice Address - Street 1:2946 LAKELAND HIGHLANDS RD
Practice Address - Street 2:HIGHLANDS PLAZA
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33803-4379
Practice Address - Country:US
Practice Address - Phone:863-583-1674
Practice Address - Fax:863-583-1678
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-07
Last Update Date:2007-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
No261QR0206XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mammography
No261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU6574Medicare PIN