MEDICARE: JACKSONVILLE BEACHES MEDICAL IMAGING 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	261QR0200X	Radiology Clinic/Center	HCCR1416	FL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	470001169	OTHER	FL	RR MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1840590	OTHER	FL	FIRST HEALTH ID
2	1416	OTHER	FL	HEALTH CARE CLINIC REG
4	V2405	OTHER	FL	BCBS PROVIDER #
5	147878900	OTHER	FL	1ST HEALTH W/C ID

General Provider Information

NPI Number	:	1801883582
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JACKSONVILLE BEACHES MEDICAL IMAGING INC

Provider Business Mailing Address
First Line	:	3316 3RD ST S
Second Line	:	SUITE 101
City	:	JACKSONVILLE BEACH
State	:	FL
Zip	:	32250-6073
Country	:	US
Telephone Number	:	904-241-7772
Fax Number	:	904-241-7702

Provider Business Practice Location Address
First Line	:	3316 3RD ST S
Second Line	:	SUITE 101
City	:	JACKSONVILLE BEACH
State	:	FL
Zip	:	32250-6073
Country	:	US
Telephone Number	:	904-241-7772
Fax Number	:	904-241-7702

Authorized Official
Title or Position	:	CHIEF OPERATING OFFICER
Name	:	MRS. CATHY BLAESE
Credential	:
Telephone Number	:	904-241-7772

Provider Enumeration Date	:	09/29/2005
Last Update Date	:	10/02/2012

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