| Entity Name: | SUNCOAST RADIOLOGY, P.A. |
| Jurisdiction: | FLORIDA |
| Filing Type: | Domestic Profit |
| Status: | Inactive |
| Date Filed: | 26 Nov 1969 (55 years ago) |
| Document Number: | 601716 |
| FEI/EIN Number | 591276138 |
| Address: | 6 FERNWOOD TRAIL, ORMOND BEACH, FL, 32174 |
| Mail Address: | 6 FERNWOOD TRAIL, ORMOND BEACH, FL, 32174 |
| ZIP code: | 32174 |
| County: | Volusia |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1083670871 | 2006-04-21 | 2007-12-12 | 500 MEMORIAL CIRCLE, SUITE B, ORMOND BEACH, FL, 321745054, US | 500 MEMORIAL CIRCLE, SUITE B, ORMOND BEACH, FL, 321745054, US | |||||||||||||||||||||||||||||||||
|
|||||||||||||||||||||||||||||||||||||
| Phone | +1 386-673-8040 |
| Fax | 3862670693 |
Authorized person
| Name | MS. JT TENER |
| Role | HUMAN RESOURCES/CREDENTIALING |
| Phone | 3866738040 |
Taxonomy
| Taxonomy Code | 2085R0202X - Diagnostic Radiology Physician |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | BCBS GROUP NUMBER |
| Number | 00400 |
| State | FL |
| Issuer | RR MEDICARE ID |
| Number | CB5023 |
| State | FL |
| Issuer | RR MEDICARE ID |
| Number | CG7286 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| MONSOUR FREDERICK J | Agent | 6 FERNWOOD TRAIL, ORMOND BEACH, FL, 32174 |
| Name | Role | Address |
|---|---|---|
| PINEIRO SERGIO J | Secretary | 19 CAMBRIDGE TRACE, ORMOND BEACH, FL, 32174 |
| Name | Role | Address |
|---|---|---|
| MONSOUR FREDERICK J | Director | 6 FERNWOOD TRAIL, ORMOND BEACH, FL, 32174 |
| PINEIRO SERGIO J | Director | 19 CAMBRIDGE TRACE, ORMOND BEACH, FL, 32174 |
| WEAVER JAMES W | Director | 3548 JOHN ANDERSON DRIVE, ORMOND BEACH, FL, 32176 |
| LEB ROBERT B | Director | 26 EMERALD CIRCLE, ORMOND BEACH, FL, 32174 |
| Name | Role | Address |
|---|---|---|
| MONSOUR FREDERICK J | Vice President | 6 FERNWOOD TRAIL, ORMOND BEACH, FL, 32174 |
| LEB ROBERT B | Vice President | 26 EMERALD CIRCLE, ORMOND BEACH, FL, 32174 |
| Name | Role | Address |
|---|---|---|
| WEAVER JAMES W | President | 3548 JOHN ANDERSON DRIVE, ORMOND BEACH, FL, 32176 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2013-09-27 | No data | No data |
| NAME CHANGE AMENDMENT | 2001-02-27 | SUNCOAST RADIOLOGY, P.A. | No data |
| NAME CHANGE AMENDMENT | 1999-02-03 | ORMOND RADIOLOGY ASSOCIATES, P.A. | No data |
| AMENDMENT | 1987-12-17 | No data | No data |
| NAME CHANGE AMENDMENT | 1976-08-02 | DEARMAS RADIOLOGY ASSOCIATES, P.A. | No data |
Date of last update: 02 Feb 2025
Sources: Florida Department of State
