MEDICARE: SPACE COAST RADIOLOGY ASSOCIATES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2085R0202X	Diagnostic Radiology Physician		FL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	CK0840	OTHER	FL	RR MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	00250	OTHER	FL	BCBS PROVIDER NUMBER
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
6	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1396794566
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPACE COAST RADIOLOGY ASSOCIATES

Provider Business Mailing Address
First Line	:	PO BOX 3148
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46206-3148
Country	:	US
Telephone Number	:	855-206-8407
Fax Number	:

Provider Business Practice Location Address
First Line	:	951 N WASHINGTON AVE
Second Line	:
City	:	TITUSVILLE
State	:	FL
Zip	:	32796-2163
Country	:	US
Telephone Number	:	321-268-6192
Fax Number	:

Authorized Official
Title or Position	:	VICE PRESIDENT
Name	:	DR. JOSEPH FLYNN
Credential	:	D. O.
Telephone Number	:	321-268-6192

Provider Enumeration Date	:	05/08/2006
Last Update Date	:	07/21/2022

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