Healthcare Provider Details

I. General information

NPI: 1013683838
Provider Name (Legal Business Name): RADIOLOGY REGIONAL CENTER, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2021
Last Update Date: 06/20/2024
Certification Date: 01/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18300 MURDOCK CIR BLDG 15
PORT CHARLOTTE FL
33948-1117
US

IV. Provider business mailing address

3660 BROADWAY
FORT MYERS FL
33901-8005
US

V. Phone/Fax

Practice location:
  • Phone: 941-255-7901
  • Fax: 941-255-7910
Mailing address:
  • Phone: 239-936-2316
  • Fax: 239-834-6106

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: RANDOLPH KNIFIC
Title or Position: CEO
Credential: MD
Phone: 239-936-2316