NPIMap

Organization Active NPI

Florida Radiology Imaging at Lake Mary, LLC

Doing business as AdventHealth Imaging Lake Nona

  • Diagnostic Radiology Physician
  • Orlando, FL
National Provider Identifier
1003208620
Registry record updated Feb 11, 2019
On this page

Key facts

NPPES NPI Registry
Primary specialty
Diagnostic Radiology PhysicianTaxonomy code 2085R0202X
Legal business name
FLORIDA RADIOLOGY IMAGING AT LAKE MARY, LLC
Doing business as
AdventHealth Imaging Lake Nona
Practice address
9975 Tavistock Lakes Blvd
Suite 120
Orlando, FL 32827-7559
Phone
(407) 200-2865
NPI assigned
Feb 19, 2015
Last updated
Feb 11, 2019By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 11, 2019

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Warren Wylie
Title
VP Radiology Enterprise
Phone
(407) 303-3358

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Diagnostic Radiology PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 2085R0202X Primary

Addresses

Primary practice location

9975 Tavistock Lakes Blvd
Suite 120
Orlando, FL 32827-7559

Mailing address

9975 Tavistock Lakes Blvd
Suite 120
Orlando, FL 32827-7559

Other names 1

  • AdventHealth Imaging Lake Nona Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in FL

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20040721001414 FL Part B Supplier - Clinic/Group Practice 1254311137 Receives reassigned benefits from 420 practitioners
8 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Orlando, FL; Oviedo, FL; Palm Beach Gardens, FL; Parkland, FL; Port Orange, FL; Vero Beach, FL; Weston, FL; Wilton Manors, FL…

Other NPIs on the same Medicare enrollment 8

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
10D2094029Adventhealth Imaging Lake Nona9975 Tavistock Lakes Blvd Ste 120, Orlando, FL 32827Certificate of waiverApr 7, 2027

National Provider Directory

National Provider Directory

Locations

9975 Tavistock Lakes Blvd
Ste 120
Orlando, FL 32827
Phone (407) 200-2865

Practitioners & affiliated clinicians

Practitioners 65

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 65

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1424304000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1549843200000",
    "number": "1003208620",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "9975 TAVISTOCK LAKES BLVD",
            "address_2": "SUITE 120",
            "city": "ORLANDO",
            "state": "FL",
            "postal_code": "328277559"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "9975 TAVISTOCK LAKES BLVD",
            "address_2": "SUITE 120",
            "city": "ORLANDO",
            "state": "FL",
            "postal_code": "328277559",
            "telephone_number": "407-200-2865"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "FLORIDA RADIOLOGY IMAGING AT LAKE MARY, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2015-02-19",
        "last_updated": "2019-02-11",
        "status": "A",
        "authorized_official_last_name": "WYLIE",
        "authorized_official_first_name": "WARREN",
        "authorized_official_title_or_position": "VP RADIOLOGY ENTERPRISE",
        "authorized_official_telephone_number": "407-303-3358"
    },
    "taxonomies": [
        {
            "code": "2085R0202X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Radiology, Diagnostic Radiology",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "AdventHealth Imaging Lake Nona",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Orlando, FL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 11, 2019; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.