Provider Demographics
NPI:1194778241
Name:CARROLLWOOD DIAGNOSTIC IMAGING
Entity type:Organization
Organization Name:CARROLLWOOD DIAGNOSTIC IMAGING
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ELLIS
Authorized Official - Middle Name:B
Authorized Official - Last Name:NORSOPH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:813-899-6220
Mailing Address - Street 1:PO BOX 47269
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33647-0111
Mailing Address - Country:US
Mailing Address - Phone:813-899-6220
Mailing Address - Fax:813-985-8006
Practice Address - Street 1:7171 N DALE MABRY HWY
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33614-2630
Practice Address - Country:US
Practice Address - Phone:813-932-2222
Practice Address - Fax:813-985-8006
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL114748 00002085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLV2765OtherBCBS OF FLORIDA
FLV2765OtherBCBS OF FLORIDA