=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801883582
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JACKSONVILLE BEACHES MEDICAL IMAGING INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/29/2005
-----------------------------------------------------
Last Update Date | 10/02/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3316 3RD ST S SUITE 101
-----------------------------------------------------
City | JACKSONVILLE BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32250-6073
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-241-7772
-----------------------------------------------------
Fax | 904-241-7702
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3316 3RD ST S SUITE 101
-----------------------------------------------------
City | JACKSONVILLE BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32250-6073
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-241-7772
-----------------------------------------------------
Fax | 904-241-7702
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF OPERATING OFFICER
-----------------------------------------------------
Name | MRS. CATHY BLAESE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 904-241-7772
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0200X
-----------------------------------------------------
Taxonomy Name | Radiology Clinic/Center
-----------------------------------------------------
License Number | HCCR1416
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------