| Entity Name: | MAVERICK MEDICAL VENTURES, INC. |
| Jurisdiction: | FLORIDA |
| Filing Type: | Domestic Profit |
| Status: | Inactive |
| Date Filed: | 16 Nov 1998 (26 years ago) |
| Date of dissolution: | 31 Mar 2011 (14 years ago) |
| Last Event: | VOLUNTARY DISSOLUTION |
| Event Date Filed: | 31 Mar 2011 (14 years ago) |
| Document Number: | P98000097428 |
| FEI/EIN Number | 522138397 |
| Address: | 1409 WEST SWANN AVE., TAMPA, FL, 33606 |
| Mail Address: | 1409 WEST SWANN AVE., TAMPA, FL, 33606 |
| ZIP code: | 33606 |
| County: | Hillsborough |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| 1548345234 | 2006-10-25 | 2020-08-22 | 3501 CATTLEMEN RD, SUITE C, SARASOTA, FL, 342326055, US | 3501 CATTLEMEN RD, SUITE C, SARASOTA, FL, 342326055, US | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| Phone | +1 941-342-7667 |
| Fax | 9413427847 |
Authorized person
| Name | MR. DANIEL F BAFIA |
| Role | PRESIDENT |
| Phone | 9413427667 |
Taxonomy
| Taxonomy Code | 261QR0200X - Radiology Clinic/Center |
| License Number | HCC5056 |
| State | FL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | AETNA PROVIDER NUMBER |
| Number | 7180294 |
| State | FL |
| Issuer | FIRST HEALTH PROVIDER NUM |
| Number | 2013853 |
| State | FL |
| Issuer | STAYWELL PROVIDER |
| Number | 201694 |
| State | FL |
| Issuer | AMERIGROUP PROVIDER NUMBE |
| Number | 226521 |
| State | FL |
| Issuer | BCBS PROVIDER NUMBER |
| Number | V2973 |
| State | FL |
| Issuer | CCN PROVIDER NUMBER |
| Number | 5425850 |
| State | FL |
| Issuer | MEDICARE COMPLETE |
| Number | 82030 |
| State | FL |
| Issuer | OXFORD PROVIDER |
| Number | A2545060 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| BLAIR WILLARD A | Agent | 101 E. KENNEDY BLVD., TAMPA, FL, 33602 |
| Name | Role | Address |
|---|---|---|
| LUETGERT MIKE | Director | 1409 W. SWANN AVE., TAMPA, FL, 33606 |
| Name | Role | Address |
|---|---|---|
| LUETGERT MIKE | President | 1409 W. SWANN AVE., TAMPA, FL, 33606 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| VOLUNTARY DISSOLUTION | 2011-03-31 | No data | No data |
| CHANGE OF PRINCIPAL ADDRESS | 2010-05-27 | 1409 WEST SWANN AVE., TAMPA, FL 33606 | No data |
| REGISTERED AGENT NAME CHANGED | 2010-05-27 | BLAIR, WILLARD AESQ. | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2010-05-27 | 101 E. KENNEDY BLVD., SUITE 2800, TAMPA, FL 33602 | No data |
| CHANGE OF MAILING ADDRESS | 2010-05-27 | 1409 WEST SWANN AVE., TAMPA, FL 33606 | No data |
| CANCEL ADM DISS/REV | 2004-10-20 | No data | No data |
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2004-10-01 | No data | No data |
| Name | Date |
|---|---|
| Voluntary Dissolution | 2011-03-31 |
| Reg. Agent Change | 2010-05-27 |
| ANNUAL REPORT | 2010-04-26 |
| ANNUAL REPORT | 2009-05-01 |
| ANNUAL REPORT | 2008-04-18 |
| ANNUAL REPORT | 2007-05-25 |
| ANNUAL REPORT | 2006-05-02 |
| ANNUAL REPORT | 2005-05-02 |
| ANNUAL REPORT | 2004-10-20 |
| ANNUAL REPORT | 2003-02-17 |
Date of last update: 03 Feb 2025
Sources: Florida Department of State
