MEDICARE: ST. JUDE RADIOLOGY MEDICAL GROUP, INC.

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

General Provider Information

NPI Number	:	1659893626
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ST. JUDE RADIOLOGY MEDICAL GROUP, INC.

Provider Business Mailing Address
First Line	:	PO BOX 940
Second Line	:
City	:	NEWBURY PARK
State	:	CA
Zip	:	91319-0940
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7214 WAREHAM DR
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33647-1166
Country	:	US
Telephone Number	:	714-992-3978
Fax Number	:

Authorized Official
Title or Position	:	MEDICAL DIRECTOR / CEO
Name	:	BRADLEY A. JACKSON
Credential	:	MD
Telephone Number	:	714-992-3978

Provider Enumeration Date	:	07/12/2017
Last Update Date	:	07/12/2017

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