Basic Information
| Provider Information | |||||||||
| NPI: | 1003291535 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RADIOLOGY ASSOCIATES OF TALLAHASSEE PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1678 | ||||||||
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| City: | TALLAHASSEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 323021678 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8508784127 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1300 MICCOSUKEE RD | ||||||||
| Address2: | |||||||||
| City: | TALLAHASSEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 323085054 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8504311155 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2015 | ||||||||
| LastUpdateDate: | 07/27/2015 | ||||||||
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| AuthorizedOfficialLastName: | DETELICH | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8508784127 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 053297501 | 05 | FL | MEDICAID | 053297505 | 05 | FL | MEDICAID | 00060 | 01 | FL | BLUE CROSS OF FLORIDA | OTHER | 053297504 | 05 | FL | MEDICAID | 300037169A | 05 | GA | MEDICAID | CA6404 | 01 | FL | RR MEDICARE | OTHER |