Provider Demographics
NPI:1528046745
Name:MEDICAL IMAGING PROFESSIONALS PA
Entity type:Organization
Organization Name:MEDICAL IMAGING PROFESSIONALS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:FRED
Authorized Official - Middle Name:S
Authorized Official - Last Name:WITTENSTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-253-3333
Mailing Address - Street 1:PO BOX 14457
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33766-4457
Mailing Address - Country:US
Mailing Address - Phone:727-793-9300
Mailing Address - Fax:727-712-4688
Practice Address - Street 1:1000 WATERMAN WAY
Practice Address - Street 2:ATTN: RADIOLOGY DEPT
Practice Address - City:TAVARES
Practice Address - State:FL
Practice Address - Zip Code:32778-5266
Practice Address - Country:US
Practice Address - Phone:352-253-3333
Practice Address - Fax:352-253-3669
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-06
Last Update Date:2015-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL269797100Medicaid
FL269797102Medicaid
FLK7028Medicare PIN