Provider Demographics
NPI:1316673668
Name:ADVENTHEALTH IMAGING CENTER PORT ORANGE
Entity type:Organization
Organization Name:ADVENTHEALTH IMAGING CENTER PORT ORANGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP/CFO
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MAZERES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-200-2227
Mailing Address - Street 1:5821 S. WILLIAMSON BLVD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32128
Mailing Address - Country:US
Mailing Address - Phone:386-231-2951
Mailing Address - Fax:386-231-2952
Practice Address - Street 1:5821 S. WILLIAMSON BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32128
Practice Address - Country:US
Practice Address - Phone:386-231-2951
Practice Address - Fax:386-231-2952
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FLORIDA RADIOLOGY IMAGING AT LAKE MARY, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-07-28
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology