Healthcare Provider Details

I. General information

NPI: 1639129521
Provider Name (Legal Business Name): TALLAHASSEE DIAG IMAGING CTR LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2006
Last Update Date: 05/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 PHILLIPS RD
TALLAHASSEE FL
32308-5304
US

IV. Provider business mailing address

PO BOX 21348
TAMPA FL
33622-1348
US

V. Phone/Fax

Practice location:
  • Phone: 850-878-4127
  • Fax: 850-878-9729
Mailing address:
  • Phone: 850-878-4127
  • Fax: 850-942-4155

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2085N0904X
TaxonomyNuclear Radiology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2085P0229X
TaxonomyPediatric Radiology Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code2085U0001X
TaxonomyDiagnostic Ultrasound Physician
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code2471C3401X
TaxonomyComputed Tomography Radiologic Technologist
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code2471M1202X
TaxonomyMagnetic Resonance Imaging Radiologic Technologist
License Number
License Number State
# 9
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: JOHN R DETELICH
Title or Position: CEO
Credential:
Phone: 850-671-6412