Provider Demographics
NPI:1427049931
Name:RADIOLOGY & IMAGING SPECIALISTS OF LAKELAND
Entity type:Organization
Organization Name:RADIOLOGY & IMAGING SPECIALISTS OF LAKELAND
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:J
Authorized Official - Last Name:GOODEMOTE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, RN
Authorized Official - Phone:863-688-2334
Mailing Address - Street 1:PO BOX 20027
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33622-0027
Mailing Address - Country:US
Mailing Address - Phone:866-804-7649
Mailing Address - Fax:614-764-9147
Practice Address - Street 1:2115 CRYSTAL GROVE DR
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33801-6875
Practice Address - Country:US
Practice Address - Phone:863-688-2334
Practice Address - Fax:863-577-0301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-03
Last Update Date:2023-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL045292104Medicaid
FL045292103Medicaid
FL045292107Medicaid
FL00584OtherBCBS OF FLORIDA
FL045292100Medicaid
FL045292105Medicaid
FL045292101Medicaid
FL045292106Medicaid
FLCC6469OtherRR MEDICARE
FL045292106Medicaid
FL045292101Medicaid
FL045292106Medicaid
FL045292105Medicaid