Provider Demographics
NPI:1285240192
Name:OHI WEST MEDICAL GROUP, LLC
Entity type:Organization
Organization Name:OHI WEST MEDICAL GROUP, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SR. DIRECTOR, OHRI
Authorized Official - Prefix:
Authorized Official - First Name:YESENIA
Authorized Official - Middle Name:
Authorized Official - Last Name:MOSHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-842-3777
Mailing Address - Street 1:3090 CARUSO CT STE 50
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-8510
Mailing Address - Country:US
Mailing Address - Phone:407-481-7174
Mailing Address - Fax:
Practice Address - Street 1:2201 CENTRAL AVE STE 100
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33713-8844
Practice Address - Country:US
Practice Address - Phone:727-893-6050
Practice Address - Fax:727-893-6046
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-17
Last Update Date:2023-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty