Healthcare Provider Details

I. General information

NPI: 1548291628
Provider Name (Legal Business Name): PENSACOLA RADIOLOGY CONSULTANTS PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/06/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5151 N 9TH AVE
PENSACOLA FL
32504-8721
US

IV. Provider business mailing address

PO BOX 9210
PENSACOLA FL
32513-9210
US

V. Phone/Fax

Practice location:
  • Phone: 850-416-6020
  • Fax:
Mailing address:
  • Phone: 850-476-8602
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. ANTHONY J. DERAIMO
Title or Position: PRESIDENT
Credential: M.D.
Phone: 850-476-8602