Healthcare Provider Details

I. General information

NPI: 1912725771
Provider Name (Legal Business Name): RADIOLOGY ASSOCIATES OF TALLAHASSEE PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2024
Last Update Date: 10/01/2024
Certification Date: 09/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1002 N ARNOLD RD STE 101
PANAMA CITY BEACH FL
32413-2291
US

IV. Provider business mailing address

PO BOX 20747
TAMPA FL
33622-0747
US

V. Phone/Fax

Practice location:
  • Phone: 850-238-4100
  • Fax: 706-653-1230
Mailing address:
  • Phone: 800-475-6112
  • Fax: 706-653-1230

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: JOHN R DETELICH
Title or Position: CEO
Credential:
Phone: 850-878-4127