Provider Demographics
NPI:1295069672
Name:SRA VENTURES INC
Entity type:Organization
Organization Name:SRA VENTURES INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:C.E.O.
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:
Authorized Official - Last Name:ABOUD
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:727-835-1450
Mailing Address - Street 1:501 S LINCOLN AVE
Mailing Address - Street 2:#15
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33756-5945
Mailing Address - Country:US
Mailing Address - Phone:727-446-6760
Mailing Address - Fax:727-441-2465
Practice Address - Street 1:2040 SHORT AVE
Practice Address - Street 2:#103
Practice Address - City:ODESSA
Practice Address - State:FL
Practice Address - Zip Code:33556-3445
Practice Address - Country:US
Practice Address - Phone:727-835-1450
Practice Address - Fax:727-835-1470
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-01
Last Update Date:2010-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE4187OtherMEDICARE PTAN