MEDICARE: NORTHSIDE IMAGING 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	2085R0202X	Diagnostic Radiology Physician

General Provider Information

NPI Number	:	1740351477
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHSIDE IMAGING LLC

Provider Business Mailing Address
First Line	:	122 LINSLEY AVENUE
Second Line	:	SUITE A
City	:	BRANDON
State	:	FL
Zip	:	33511
Country	:	US
Telephone Number	:	813-657-4914
Fax Number	:	813-657-4916

Provider Business Practice Location Address
First Line	:	6006 49TH STREET NORTH
Second Line	:	SUITE 140
City	:	ST PETERSBURG
State	:	FL
Zip	:	33709
Country	:	US
Telephone Number	:	727-528-5900
Fax Number	:	727-528-5913

Authorized Official
Title or Position	:	SENIOR VICE PRESIDENT
Name	:	MR. ROBERT SAMUEL HANKINS JR.
Credential	:
Telephone Number	:	615-344-2274

Provider Enumeration Date	:	11/13/2006
Last Update Date	:	08/22/2020

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Directions to “NORTHSIDE IMAGING LLC ” Practice Location

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