MEDICARE: RADIOLOGY REGIONAL CENTER, PA

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	2085R0202X	Diagnostic Radiology Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1730855511
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RADIOLOGY REGIONAL CENTER, PA

Provider Business Mailing Address
First Line	:	3660 BROADWAY
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33901-8005
Country	:	US
Telephone Number	:	239-936-2316
Fax Number	:	239-834-6106

Provider Business Practice Location Address
First Line	:	1110 LEE BLVD
Second Line	:
City	:	LEHIGH ACRES
State	:	FL
Zip	:	33936-4844
Country	:	US
Telephone Number	:	239-344-1000
Fax Number	:	239-344-1035

Authorized Official
Title or Position	:	CEO
Name	:	BRIAN A KRIVISKY
Credential	:	MD
Telephone Number	:	239-936-2316

Provider Enumeration Date	:	08/20/2021
Last Update Date	:	08/20/2021

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