Healthcare Provider Details

I. General information

NPI: 1811662679
Provider Name (Legal Business Name): RADIOLOGY & IMAGING SPECIALISTS OF LAKELAND
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/13/2021
Last Update Date: 08/13/2021
Certification Date: 07/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3221 S FLORIDA AVE STE B
LAKELAND FL
33803-4550
US

IV. Provider business mailing address

PO BOX 20027
TAMPA FL
33622-0027
US

V. Phone/Fax

Practice location:
  • Phone: 863-577-0296
  • Fax:
Mailing address:
  • Phone:
  • 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: EDWARD J GOODEMOTE
Title or Position: CEO
Credential:
Phone: 863-577-0303