Basic Information
| Provider Information | |||||||||
| NPI: | 1821061144 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ST JOSEPH'S DIAGNOSTIC CENTER,LTD | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | CARROLLWOOD | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | P O BOX 403800 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303840001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8138523272 | ||||||||
| FaxNumber: | 8138523233 | ||||||||
| Practice Location | |||||||||
| Address1: | 14310 N DALE MABRY HWY | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336182059 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8139602808 | ||||||||
| FaxNumber: | 8138523233 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | INZINA | ||||||||
| AuthorizedOfficialFirstName: | TOMMY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXEC VP | ||||||||
| AuthorizedOfficialTelephone: | 7278208004 | ||||||||
| 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 | 061048800 | 05 | FL | MEDICAID |