Provider Demographics
NPI:1801883582
Name:JACKSONVILLE BEACHES MEDICAL IMAGING INC
Entity type:Organization
Organization Name:JACKSONVILLE BEACHES MEDICAL IMAGING INC
Other - Org Name:
Other - Org Type:
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 1:3316 3RD ST S
Mailing Address - Street 2:SUITE 101
Mailing Address - City:JACKSONVILLE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32250-6073
Mailing Address - Country:US
Mailing Address - Phone:904-241-7772
Mailing Address - Fax:904-241-7702
Practice Address - Street 1:3316 3RD ST S
Practice Address - Street 2:SUITE 101
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250-6073
Practice Address - Country:US
Practice Address - Phone:904-241-7772
Practice Address - Fax:904-241-7702
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-29
Last Update Date:2012-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLHCCR1416261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1840590OtherFIRST HEALTH ID
FL1416OtherHEALTH CARE CLINIC REG
FL470001169OtherRR MEDICARE
FLV2405OtherBCBS PROVIDER #
FL147878900Other1ST HEALTH W/C ID
FL147878900Other1ST HEALTH W/C ID