Basic Information
| Provider Information | |||||||||
| NPI: | 1417111881 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST ANTHONYS PROFESSIONAL BUILDINGS & SERVICES INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SA TYRONE IMAGING CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 403795 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303843795 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8138523272 | ||||||||
| FaxNumber: | 8138523244 | ||||||||
| Practice Location | |||||||||
| Address1: | 3201 66TH ST N | ||||||||
| Address2: | |||||||||
| City: | ST PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337101510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7273452600 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2008 | ||||||||
| LastUpdateDate: | 07/15/2008 | ||||||||
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| AuthorizedOfficialLastName: | TREMONTI | ||||||||
| AuthorizedOfficialFirstName: | CARL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 7278251649 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 2607697-00 | 05 | FL | MEDICAID |