Provider Demographics
NPI:1568459055
Name:JACKSONVILLE BEACHES MEDICAL IMAGING INC
Entity Type:Organization
Organization Name:JACKSONVILLE BEACHES MEDICAL IMAGING INC
Other - Org Name:SOUTHSIDE MEDICAL IMAGING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:BLAESE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-241-7772
Mailing Address - Street 1:6138 KENNERLY RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-4345
Mailing Address - Country:US
Mailing Address - Phone:904-733-7770
Mailing Address - Fax:904-733-7778
Practice Address - Street 1:6138 KENNERLY RD
Practice Address - Street 2:SUITE 101
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-4345
Practice Address - Country:US
Practice Address - Phone:904-733-7770
Practice Address - Fax:904-733-7778
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-30
Last Update Date:2012-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLHCCR1418261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1840590Other1ST HEALTH PROVIDER
FL7842141OtherAETNA PROVIDER #
FLV2499OtherBCBS VIN #
FL2052827OtherUNITED HEALTH CARE
FL470001168OtherRR MEDICARE PIN
FL147878601Other1ST HEALTH W/C #
FL147878601Other1ST HEALTH W/C #