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General NPI Number Information
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NPI Number | 1396794566
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Entity Type | Organization
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Legal Business Name | SPACE COAST RADIOLOGY ASSOCIATES
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Dates
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Enumeration Date | 05/08/2006
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 951 N WASHINGTON AVE
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City | TITUSVILLE
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State | FL
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Zip | 32796-2163
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Country | US
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Telephone | 321-268-6192
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 3148
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City | INDIANAPOLIS
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State | IN
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Zip | 46206-3148
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Country | US
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Telephone | 855-206-8407
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Fax |
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Authorized Official
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Title or Position | VICE PRESIDENT
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Name | DR. JOSEPH FLYNN
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Credential | D. O.
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Telephone | 321-268-6192
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number |
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License Number State | FL
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