Healthcare Provider Details

I. General information

NPI: 1467499863
Provider Name (Legal Business Name): BLOOMINGDALE RADIOLOGY CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3350 BELL SHOALS RD
BRANDON FL
33511-7637
US

IV. Provider business mailing address

PO BOX 931083
ATLANTA GA
31193-1083
US

V. Phone/Fax

Practice location:
  • Phone: 813-654-4883
  • Fax: 813-676-0339
Mailing address:
  • Phone: 772-600-0324
  • Fax: 772-600-0327

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License NumberHCC3759
License Number StateFL

VIII. Authorized Official

Name: THOMAS G WINTER
Title or Position: PRESIDENT
Credential:
Phone: 772-463-8256