Provider Demographics
NPI:1114950672
Name:ST. JOHNS RADIOLOGY ASSOC. P.A.
Entity Type:Organization
Organization Name:ST. JOHNS RADIOLOGY ASSOC. P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DEBBIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:NEALING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-829-5960
Mailing Address - Street 1:301 HEALTH PARK BLVD STE 217
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-5795
Mailing Address - Country:US
Mailing Address - Phone:904-824-8813
Mailing Address - Fax:
Practice Address - Street 1:301 HEALTH PARK BLVD. SUITE 217
Practice Address - Street 2:
Practice Address - City:ST. AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086
Practice Address - Country:US
Practice Address - Phone:904-824-8813
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL98830Medicare ID - Type UnspecifiedGROUP NUMBER