MEDICARE: FLORIDA RADIOLOGY IMAGING AT LAKE MARY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	2085N0700X	Neuroradiology Physician
2	2085R0204X	Vascular & Interventional Radiology Physician
3	2085U0001X	Diagnostic Ultrasound Physician
4	2085R0202X	Diagnostic Radiology Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	V3162	OTHER	FL	BCBS GROUP NUMBER

General Provider Information

NPI Number	:	1003983610
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FLORIDA RADIOLOGY IMAGING AT LAKE MARY LLC

Provider Business Mailing Address
First Line	:	PO BOX 150130
Second Line	:
City	:	ALTAMONTE SPRINGS
State	:	FL
Zip	:	32715-0130
Country	:	US
Telephone Number	:	407-767-5028
Fax Number	:	407-767-8443

Provider Business Practice Location Address
First Line	:	6000 TURKEY LAKE RD
Second Line	:	SUITE 107
City	:	ORLANDO
State	:	FL
Zip	:	32819-4200
Country	:	US
Telephone Number	:	407-834-8722
Fax Number	:	407-834-5325

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	BRIAN REEVES
Credential	:	D.O.
Telephone Number	:	407-834-8722

Provider Enumeration Date	:	11/29/2006
Last Update Date	:	02/25/2008

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