MEDICARE: ULTRA IMAGING OF TAMPA LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	261QR0206X	Mammography Clinic/Center
2	261QM1200X	Magnetic Resonance Imaging (MRI) Clinic/Center
3	261QR0200X	Radiology Clinic/Center

General Provider Information

NPI Number	:	1427055177
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ULTRA IMAGING OF TAMPA LLC

Provider Business Mailing Address
First Line	:	13787 BELCHER RD S
Second Line	:	STE 300
City	:	LARGO
State	:	FL
Zip	:	33771-4065
Country	:	US
Telephone Number	:	813-657-4914
Fax Number	:	813-657-4916

Provider Business Practice Location Address
First Line	:	13787 BELCHER RD S
Second Line	:	SUITE 300
City	:	LARGO
State	:	FL
Zip	:	33771-4065
Country	:	US
Telephone Number	:	727-497-1674
Fax Number	:	727-497-4674

Authorized Official
Title or Position	:	CREDENTIALING COORDINATOR
Name	:	MR. LAVELLE R HARDIN
Credential	:
Telephone Number	:	615-344-8203

Provider Enumeration Date	:	07/07/2005
Last Update Date	:	08/02/2007

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