Provider Demographics
NPI:1538551320
Name:PROFESSIONAL RADIOLOGY ASSOCIATES PA
Entity type:Organization
Organization Name:PROFESSIONAL RADIOLOGY ASSOCIATES PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:A
Authorized Official - Last Name:LORD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-379-2226
Mailing Address - Street 1:100 BAYVIEW CIR
Mailing Address - Street 2:400
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-2983
Mailing Address - Country:US
Mailing Address - Phone:949-242-5592
Mailing Address - Fax:
Practice Address - Street 1:4634 SUMMERDALE DR
Practice Address - Street 2:
Practice Address - City:PACE
Practice Address - State:FL
Practice Address - Zip Code:32571-1368
Practice Address - Country:US
Practice Address - Phone:904-379-2226
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-03
Last Update Date:2015-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology