=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629162904
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ROSE RADIOLOGY CENTERS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/03/2006
-----------------------------------------------------
Last Update Date | 04/07/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4133 WOODLANDS PKWY
-----------------------------------------------------
City | PALM HARBOR
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34685-3462
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-781-3888
-----------------------------------------------------
Fax | 727-784-0616
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8300 W SUNRISE BLVD
-----------------------------------------------------
City | PLANTATION
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33322-5406
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-781-3888
-----------------------------------------------------
Fax | 727-784-0616
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SENIOR VICE PRESIDENT
-----------------------------------------------------
Name | LAURA KASSA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 904-300-2777
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | ME51729
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QR0200X
-----------------------------------------------------
Taxonomy Name | Radiology Clinic/Center
-----------------------------------------------------
License Number | ME51729
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------