Provider Demographics
NPI:1386882272
Name:A1 IMAGING OF KISSIMMEE LLC
Entity type:Organization
Organization Name:A1 IMAGING OF KISSIMMEE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:MARILYN
Authorized Official - Middle Name:
Authorized Official - Last Name:RADAKOVIC
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:951-315-6661
Mailing Address - Street 1:2 N TAMIAMI TRAIL
Mailing Address - Street 2:SUITE 210
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34236-5574
Mailing Address - Country:US
Mailing Address - Phone:941-925-3490
Mailing Address - Fax:941-953-4452
Practice Address - Street 1:810 N JOHN YOUNG PKWY
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-4912
Practice Address - Country:US
Practice Address - Phone:407-847-6745
Practice Address - Fax:407-847-8749
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:A1 IMAGING CENTERS LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-01-30
Last Update Date:2014-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLHCC7759261QM1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLBA926Medicare PIN