Healthcare Provider Details

I. General information

NPI: 1619365772
Provider Name (Legal Business Name): RADIOLOGY REGIONAL CENTER PROFESSIONAL SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/24/2014
Last Update Date: 06/18/2020
Certification Date: 06/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13681 DOCTORS WAY
FORT MYERS FL
33912-4300
US

IV. Provider business mailing address

3660 BROADWAY
FORT MYERS FL
33901-8005
US

V. Phone/Fax

Practice location:
  • Phone: 239-343-1000
  • Fax:
Mailing address:
  • Phone: 239-936-2316
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: BRIAN A KRIVISKY
Title or Position: PRESIDENT
Credential: MD
Phone: 239-931-6376