Summerlin Imaging Center LLC

Primary specialty

Diagnostic Radiology PhysicianTaxonomy code 2085R0202X

Legal business name

SUMMERLIN IMAGING CENTER LLC

Practice address

2128 Park Ave
Orange Park, FL 32073

Phone

(904) 375-8884

Fax

(904) 375-8887

NPI assigned

Sep 14, 2016

Organization subpart

No

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

Authorized official

Name

Mr. Bradford Peters

Title

Cfo

Phone

(561) 331-0808

Specialties & licenses 1

Addresses

Other identifiers 1

Other names 1

• Park Avenue Imaging Other name

Locations

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

{
    "created_epoch": "1473811200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1598313600000",
    "number": "1720536154",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "6415 LAKE WORTH RD STE 102",
            "city": "GREENACRES",
            "state": "FL",
            "postal_code": "334633009",
            "telephone_number": "561-331-0808",
            "fax_number": "561-237-6034"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2128 PARK AVE",
            "city": "ORANGE PARK",
            "state": "FL",
            "postal_code": "32073",
            "telephone_number": "904-375-8884",
            "fax_number": "904-375-8887"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SUMMERLIN IMAGING CENTER LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2016-09-14",
        "last_updated": "2020-08-25",
        "certification_date": "2020-08-25",
        "status": "A",
        "authorized_official_last_name": "PETERS",
        "authorized_official_first_name": "BRADFORD",
        "authorized_official_title_or_position": "CFO",
        "authorized_official_telephone_number": "561-331-0808",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "2085R0202X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Radiology, Diagnostic Radiology",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "AHCC LICENSE",
            "identifier": "HCC10650",
            "state": "FL"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Park Avenue Imaging",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

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• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 25, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.