Provider Demographics
NPI:1386316602
Name:FLORIDA RADIOLOGY IMAGING AT LAKE MARY, LLC
Entity type:Organization
Organization Name:FLORIDA RADIOLOGY IMAGING AT LAKE MARY, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
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:407-357-1912
Mailing Address - Street 1:235 E PRINCETON ST STE 100
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32804-5554
Mailing Address - Country:US
Mailing Address - Phone:407-303-1414
Mailing Address - Fax:
Practice Address - Street 1:1919 E HIGHWAY 50 STE 101
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-1975
Practice Address - Country:US
Practice Address - Phone:352-717-3738
Practice Address - Fax:352-717-3739
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-05
Last Update Date:2021-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty