Provider Demographics
NPI:1700830890
Name:TALLAHASSEE DIAGNOSTIC IMAGING LTD
Entity Type:Organization
Organization Name:TALLAHASSEE DIAGNOSTIC IMAGING LTD
Other - Org Name:TALLAHASSEE DIAGNOSTIC IMAGING (TDI)
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CARA
Authorized Official - Middle Name:
Authorized Official - Last Name:FOWLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-671-6412
Mailing Address - Street 1:PO BOX 13551
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32317-3551
Mailing Address - Country:US
Mailing Address - Phone:850-878-4102
Mailing Address - Fax:850-942-4155
Practice Address - Street 1:15 COUNCIL MOORE RD
Practice Address - Street 2:
Practice Address - City:CRAWFORDVILLE
Practice Address - State:FL
Practice Address - Zip Code:32327-3117
Practice Address - Country:US
Practice Address - Phone:850-926-1259
Practice Address - Fax:850-926-1679
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TALLAHASSEE DIAGNOSTIC IMAGING LTD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-22
Last Update Date:2007-10-17
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
No2085R0203XAllopathic & Osteopathic PhysiciansRadiologyTherapeutic 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
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLV3086OtherBCBS
FL062730501Medicaid
CL1403Medicare PIN