MEDICARE: SONOLOGICS LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QR0208X	Mobile Radiology Clinic/Center

General Provider Information

NPI Number	:	1326033960
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SONOLOGICS LLC

Provider Business Mailing Address
First Line	:	1901 ROXBOROUGH RD
Second Line	:	SUITE 200
City	:	CHARLOTTE
State	:	NC
Zip	:	28211-3482
Country	:	US
Telephone Number	:	813-933-6848
Fax Number	:	813-933-7767

Provider Business Practice Location Address
First Line	:	2835 W DE LEON ST
Second Line	:	SUITE 104
City	:	TAMPA
State	:	FL
Zip	:	33609-4130
Country	:	US
Telephone Number	:	813-872-6170
Fax Number	:	813-872-6370

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. RANDALL WINBURN MOUNTCASTLE
Credential	:
Telephone Number	:	704-525-7005

Provider Enumeration Date	:	09/20/2005
Last Update Date	:	10/26/2007

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Directions to “SONOLOGICS LLC ” Practice Location

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