=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669744801
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RADIOLOGY & IMAGING SPECIALISTS OF LAKELAND, PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/03/2012
-----------------------------------------------------
Last Update Date | 08/08/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 206 W ALEXANDER ST STE 1
-----------------------------------------------------
City | PLANT CITY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33563-7100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 863-688-2334
-----------------------------------------------------
Fax | 863-577-1160
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2115 CRYSTAL GROVE DR
-----------------------------------------------------
City | LAKELAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33801-6875
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 863-688-2334
-----------------------------------------------------
Fax | 863-577-1160
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | RICHARD SORRELLS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 863-688-2334
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------