Basic Information
| Provider Information | |||||||||
| NPI: | 1003866773 | ||||||||
| 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: | 8508784102 | ||||||||
| FaxNumber: | 8509424155 | ||||||||
| Practice Location | |||||||||
| Address1: | 1600 PHILLIPS RD | ||||||||
| Address2: | |||||||||
| City: | TALLAHASSEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 323085304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8508784127 | ||||||||
| FaxNumber: | 8508780337 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2006 | ||||||||
| LastUpdateDate: | 03/14/2014 | ||||||||
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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 | 2085B0100X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Body Imaging | 2085N0700X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology | 2085N0904X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Nuclear Radiology | 2085P0229X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Pediatric Radiology | 2085R0204X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2085U0001X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Ultrasound | 2471C3401X | N | 193200000X MULTI-SPECIALTY GROUP | Technologists, Technicians & Other Technical Service Providers | Radiologic Technologist | Computed Tomography | 2085R0202X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 053297501 | 05 | FL | MEDICAID | N4026 | 05 | FL | MEDICAID | 053297500 | 05 | FL | MEDICAID | 00060 | 01 | FL | BCBS | OTHER | 053297505 | 05 | FL | MEDICAID | 053297504 | 05 | FL | MEDICAID | 300037169A | 05 | GA | MEDICAID |