1639129521 NPI number — TALLAHASSEE DIAG IMAGING CTR LTD

Table of content: (NPI 1639129521)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639129521 NPI number — TALLAHASSEE DIAG IMAGING CTR LTD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TALLAHASSEE DIAG IMAGING CTR LTD
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1639129521
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/19/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 21348
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TAMPA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33622-1348
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-878-4127
Provider Business Mailing Address Fax Number:
850-942-4155

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1600 PHILLIPS RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TALLAHASSEE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32308-5304
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-878-4127
Provider Business Practice Location Address Fax Number:
850-878-9729
Provider Enumeration Date:
05/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DETELICH
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
R
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
850-671-6412

Provider Taxonomy Codes

  • Taxonomy code: 2085B0100X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085N0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085N0904X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085P0229X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0202X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2085R0204X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085U0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2471C3401X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2471M1202X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 062730503 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: V3052 . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 062730500 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: CL1403 . This is a "RR MEDICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 98956 . This is a "BC BS FL" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: V3053 . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: V3054 . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 062730502 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 300038358C . This is a "GA MEDICAID" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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