Healthcare Provider Details

I. General information

NPI: 1124266010
Provider Name (Legal Business Name): A1 IMAGING OF ST AUGUSTINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2009
Last Update Date: 12/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 SOUTHPARK BLVD STE 210
ST AUGUSTINE FL
32086-3101
US

IV. Provider business mailing address

1800 2ND ST SUITE 915
SARASOTA FL
34236-5946
US

V. Phone/Fax

Practice location:
  • Phone: 904-819-0920
  • Fax: 904-819-0299
Mailing address:
  • Phone: 941-315-9876
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1200X
TaxonomyMagnetic Resonance Imaging (MRI) Clinic/Center
License NumberHCC7757
License Number StateFL

VIII. Authorized Official

Name: MARILYN RADAKOVIC
Title or Position: COO
Credential:
Phone: 951-285-6661