Provider Demographics
NPI:1821061144
Name:ST JOSEPH'S DIAGNOSTIC CENTER,LTD
Entity Type:Organization
Organization Name:ST JOSEPH'S DIAGNOSTIC CENTER,LTD
Other - Org Name:CARROLLWOOD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXEC VP
Authorized Official - Prefix:
Authorized Official - First Name:TOMMY
Authorized Official - Middle Name:
Authorized Official - Last Name:INZINA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-820-8004
Mailing Address - Street 1:P O BOX 403800
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-0001
Mailing Address - Country:US
Mailing Address - Phone:813-852-3272
Mailing Address - Fax:813-852-3233
Practice Address - Street 1:14310 N DALE MABRY HWY
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33618-2059
Practice Address - Country:US
Practice Address - Phone:813-960-2808
Practice Address - Fax:813-852-3233
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL061048800Medicaid