Provider Demographics
NPI:1154378800
Name:RADIOLOGY GROUP OF WEST FLORIDA INC
Entity type:Organization
Organization Name:RADIOLOGY GROUP OF WEST FLORIDA INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:D
Authorized Official - Last Name:LAURENT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-288-4624
Mailing Address - Street 1:2055 NORMANDIE DR
Mailing Address - Street 2:SUITE 108
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36111-2732
Mailing Address - Country:US
Mailing Address - Phone:334-288-4624
Mailing Address - Fax:334-280-3628
Practice Address - Street 1:8383 N DAVIS HWY
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32514-6039
Practice Address - Country:US
Practice Address - Phone:334-288-4624
Practice Address - Fax:334-280-3628
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-28
Last Update Date:2008-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL270015800Medicaid
FLK5492Medicare PIN