Provider Demographics
NPI:1134116726
Name:DESTIN REGIONAL IMAGING CENTER LLC
Entity Type:Organization
Organization Name:DESTIN REGIONAL IMAGING CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:DR
Authorized Official - First Name:CHUN
Authorized Official - Middle Name:W
Authorized Official - Last Name:CHEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-278-3555
Mailing Address - Street 1:PO BOX 1977
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46206-1977
Mailing Address - Country:US
Mailing Address - Phone:855-410-3201
Mailing Address - Fax:855-853-5098
Practice Address - Street 1:7800 US HIGHWAY 98 W
Practice Address - Street 2:
Practice Address - City:MIRAMAR BEACH
Practice Address - State:FL
Practice Address - Zip Code:32550-7228
Practice Address - Country:US
Practice Address - Phone:850-278-3555
Practice Address - Fax:850-278-3562
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-29
Last Update Date:2022-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME866152085R0202X
FLME894642085R0202X
FLME748202085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL272337900Medicaid
IND NPI 1568439883OtherDR. R JAY CROWTHER MD
IND NPI 1841287547OtherDR. BARRY F. RIGGS
FL272337900Medicaid
FL272337900Medicaid
D42258Medicare UPIN
IND NPI 1841287547OtherDR. BARRY F. RIGGS