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General NPI Number Information
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NPI Number | 1962178764
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Entity Type | Organization
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Legal Business Name | RADIOLOGY REGIONAL CENTER, PA
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Dates
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Enumeration Date | 08/20/2021
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Last Update Date | 08/20/2021
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Provider Practice Location Address
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Address Line | 805 DEL PRADO BLVD S
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City | CAPE CORAL
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State | FL
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Zip | 33990-2666
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Country | US
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Telephone | 239-458-1744
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Fax | 239-458-1955
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Provider Business Mailing Address
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Address Line | 3660 BROADWAY
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City | FORT MYERS
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State | FL
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Zip | 33901-8005
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Country | US
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Telephone | 239-936-2316
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Fax | 239-834-6106
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Authorized Official
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Title or Position | CEO
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Name | BRIAN A KRIVISKY
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Credential | MD
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Telephone | 239-936-2316
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number |
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License Number State |
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