Provider Demographics
NPI:1639129521
Name:TALLAHASSEE DIAG IMAGING CTR LTD
Entity Type:Organization
Organization Name:TALLAHASSEE DIAG IMAGING CTR LTD
Other - Org Name:TALLAHASSEE DIAGNOSTIC IMAGING LTD
Other - Org Type:Doing Business As
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:850-671-6412
Mailing Address - Street 1:PO BOX 21348
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33622-1348
Mailing Address - Country:US
Mailing Address - Phone:850-878-4127
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:850-878-9729
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-11
Last Update Date:2017-05-19
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
No2471M1202XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistMagnetic Resonance ImagingGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL062730503Medicaid
FLV3052OtherBCBS
FL062730500Medicaid
FLCL1403OtherRR MEDICARE
FL98956OtherBC BS FL
FLV3053OtherBCBS
FLV3054OtherBCBS
FL062730502Medicaid
GA300038358COtherGA MEDICAID
FLV3053OtherBCBS
FL98956Medicare PIN