MEDICARE: STAND-UP MRI OF LAKELAND, LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM1200X	Magnetic Resonance Imaging (MRI) Clinic/Center		FL

General Provider Information

NPI Number	:	1811257876
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STAND-UP MRI OF LAKELAND, LLC

Provider Business Mailing Address
First Line	:	2120 LAKELAND HILLS BLVD
Second Line	:
City	:	LAKELAND
State	:	FL
Zip	:	33805-2906
Country	:	US
Telephone Number	:	863-688-2334
Fax Number	:	863-577-0301

Provider Business Practice Location Address
First Line	:	1121 LAKELAND HILLS BLVD
Second Line	:
City	:	LAKELAND
State	:	FL
Zip	:	33805-4655
Country	:	US
Telephone Number	:	863-688-2334
Fax Number	:	863-577-0301

Authorized Official
Title or Position	:	CEO
Name	:	EDWARD J. GOODEMOTE
Credential	:	RN, PHD
Telephone Number	:	863-577-0303

Provider Enumeration Date	:	05/24/2012
Last Update Date	:	05/24/2012

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