Provider Demographics
NPI:1003866773
Name:RADIOLOGY ASSOCIATES OF TALLAHASSEE PA
Entity Type:Organization
Organization Name:RADIOLOGY ASSOCIATES OF TALLAHASSEE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:R
Authorized Official - Last Name:DETELICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-878-4127
Mailing Address - Street 1:PO BOX 1678
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32302-1678
Mailing Address - Country:US
Mailing Address - Phone:850-878-4102
Mailing Address - Fax:850-942-4155
Practice Address - Street 1:1600 PHILLIPS RD
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-5304
Practice Address - Country:US
Practice Address - Phone:850-878-4127
Practice Address - Fax:850-878-0337
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-11
Last Update Date:2014-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody ImagingGroup - Multi-Specialty
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiologyGroup - Multi-Specialty
No2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear RadiologyGroup - Multi-Specialty
No2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric RadiologyGroup - Multi-Specialty
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Multi-Specialty
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic UltrasoundGroup - Multi-Specialty
No2471C3401XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistComputed TomographyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL053297501Medicaid
FLN4026Medicaid
FL053297500Medicaid
FL00060OtherBCBS
FL053297505Medicaid
FL053297504Medicaid
GA300037169AMedicaid
CA6404Medicare PIN
GA300037169AMedicaid
FL053297500Medicaid