MEDICARE: TALLAHASSEE DIAG IMAGING CTR LTD

Medicare Provider Information

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

#	Taxonomy Code	Taxonomy
1	2085B0100X	Body Imaging Physician
2	2085N0700X	Neuroradiology Physician
3	2085N0904X	Nuclear Radiology Physician
4	2085P0229X	Pediatric Radiology Physician
5	2085R0204X	Vascular & Interventional Radiology Physician
6	2085U0001X	Diagnostic Ultrasound Physician
7	2471C3401X	Computed Tomography Radiologic Technologist
8	2471M1202X	Magnetic Resonance Imaging Radiologic Technologist
9	2085R0202X	Diagnostic Radiology Physician

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
4	CL1403	OTHER	FL	RR MEDICARE

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	V3052	OTHER	FL	BCBS
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	98956	OTHER	FL	BC BS FL
6	V3053	OTHER	FL	BCBS
7	V3054	OTHER	FL	BCBS
8	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
9	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

NPI Number	:	1639129521
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TALLAHASSEE DIAG IMAGING CTR LTD

Provider Business Mailing Address
First Line	:	PO BOX 21348
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33622-1348
Country	:	US
Telephone Number	:	850-878-4127
Fax Number	:	850-942-4155

Provider Business Practice Location Address
First Line	:	1600 PHILLIPS RD
Second Line	:
City	:	TALLAHASSEE
State	:	FL
Zip	:	32308-5304
Country	:	US
Telephone Number	:	850-878-4127
Fax Number	:	850-878-9729

Authorized Official
Title or Position	:	CEO
Name	:	JOHN R DETELICH
Credential	:
Telephone Number	:	850-671-6412

Provider Enumeration Date	:	05/11/2006
Last Update Date	:	05/19/2017