Provider Demographics
NPI:1194716126
Name:ULTRA IMAGING OF TAMPA LLC
Entity type:Organization
Organization Name:ULTRA IMAGING OF TAMPA LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:LAVELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:HARDIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-344-8203
Mailing Address - Street 1:6449 38TH AVE N
Mailing Address - Street 2:SUITE B-3
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33710-1655
Mailing Address - Country:US
Mailing Address - Phone:727-381-1674
Mailing Address - Fax:727-381-4226
Practice Address - Street 1:6449 38TH AVE N
Practice Address - Street 2:SUITE B-3
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33710-1655
Practice Address - Country:US
Practice Address - Phone:727-381-1674
Practice Address - Fax:727-381-4226
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-31
Last Update Date:2007-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK7869Medicare PIN