Provider Demographics
NPI:1265691208
Name:A1 IMAGING OF ST AUGUSTINE
Entity type:Organization
Organization Name:A1 IMAGING OF ST AUGUSTINE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:MARILYN
Authorized Official - Middle Name:
Authorized Official - Last Name:RADAKOVIC
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:951-385-6661
Mailing Address - Street 1:1800 2ND ST
Mailing Address - Street 2:SUITE 915
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34236-5930
Mailing Address - Country:US
Mailing Address - Phone:941-315-9876
Mailing Address - Fax:941-953-4452
Practice Address - Street 1:200 SOUTHPARK BLVD
Practice Address - Street 2:SUITE 210
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-3101
Practice Address - Country:US
Practice Address - Phone:904-819-0920
Practice Address - Fax:904-819-0299
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:A1 IMAGING CENTERS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-06-05
Last Update Date:2014-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLBB318Medicare PIN