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NPI Code Detail

MEDICARE: SOUTHEAST RADIOLOGY ASSOCIATES PL

MEDICARE: SOUTHEAST RADIOLOGY ASSOCIATES PL
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
12085B0100XBody Imaging Physician
22085N0700XNeuroradiology Physician
32085N0904XNuclear Radiology Physician
42085P0229XPediatric Radiology Physician
52085R0204XVascular & Interventional Radiology Physician
62085U0001XDiagnostic Ultrasound Physician
72085R0202XDiagnostic Radiology Physician

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
197561OTHERFLBCBS

General Provider Information

NPI Number : 1467409631
Entity Type Code : Organization
Provider Name (Legal Business Name) : SOUTHEAST RADIOLOGY ASSOCIATES PL
Provider Business Mailing Address
First Line : PO BOX 2293
Second Line :
City : LAKE CITY
State : FL
Zip : 32056-2293
Country : US
Telephone Number : 386-752-1316
Fax Number :
Provider Business Practice Location Address
First Line : 340 NW COMMERCE DR
Second Line :
City : LAKE CITY
State : FL
Zip : 32055-4709
Country : US
Telephone Number : 386-719-9000
Fax Number :
Authorized Official
Title or Position : CEO
Name : JOHN R DETELICH
Credential :
Telephone Number : 850-878-4127
Provider Enumeration Date : 05/31/2006
Last Update Date : 10/17/2007

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Directions to “SOUTHEAST RADIOLOGY ASSOCIATES PL ” Practice Location

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