Healthcare Provider Details

I. General information

NPI: 1346584075
Provider Name (Legal Business Name): ITF MOBILE BX, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/19/2012
Last Update Date: 11/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4128 CAUSEWAY VISTA DR
TAMPA FL
33615-5416
US

IV. Provider business mailing address

4128 CAUSEWAY VISTA DR
TAMPA FL
33615-5416
US

V. Phone/Fax

Practice location:
  • Phone: 727-505-3098
  • Fax: 813-882-3679
Mailing address:
  • Phone: 727-505-3098
  • Fax: 813-882-3679

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0208X
TaxonomyMobile Radiology Clinic/Center
License NumberME 63242
License Number StateFL

VIII. Authorized Official

Name: DR. DENIS WILLIAM STEWART
Title or Position: PRESIDENT
Credential: M.D.
Phone: 727-505-3098