Basic Information
| Provider Information | |||||||||
| NPI: | 1417525494 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RADIOLOGY ASSOCIATES OF TALLAHASSEE, PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 20747 | ||||||||
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| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336220747 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004756112 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4250 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | MARIANNA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 324461917 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004756112 | ||||||||
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| ProviderEnumerationDate: | 06/15/2021 | ||||||||
| LastUpdateDate: | 06/15/2021 | ||||||||
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| AuthorizedOfficialLastName: | DETELICH | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8508784127 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | RADIOLOGY ASSOCIATES OF TALLAHASSEE, PA | ||||||||
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| NPICertificationDate: | 06/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.