Healthcare Provider Details

I. General information

NPI: 1427115435
Provider Name (Legal Business Name): INNOVATIVE IMAGING ASSOCIATES, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/02/2007
Last Update Date: 06/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 6TH ST S
ST PETERSBURG FL
33701-4814
US

IV. Provider business mailing address

PO BOX 309
PICKENS SC
29671-0309
US

V. Phone/Fax

Practice location:
  • Phone: 727-274-2228
  • Fax:
Mailing address:
  • Phone: 864-850-1441
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberME92656
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code2085U0001X
TaxonomyDiagnostic Ultrasound Physician
License NumberME92656
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberME92656
License Number StateFL

VIII. Authorized Official

Name: NASSER RAZACK
Title or Position: OWNER
Credential: MD
Phone: 727-374-2228