Healthcare Provider Details

I. General information

NPI: 1912406984
Provider Name (Legal Business Name): RADIOLOGY & IMAGING SPECIALISTS OF LAKELAND PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2018
Last Update Date: 02/06/2018
Certification Date:
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

2125 CRYSTAL GROVE DR
LAKELAND FL
33801-6875
US

V. Phone/Fax

Practice location:
  • Phone: 863-577-0296
  • Fax:
Mailing address:
  • Phone: 863-577-0303
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: EDWARD J GOODEMOTE
Title or Position: CEO
Credential:
Phone: 863-577-0303